Provider Demographics
NPI:1033620570
Name:SMILE DENTAL CENTRALIA LLC
Entity Type:Organization
Organization Name:SMILE DENTAL CENTRALIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-263-6642
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-0306
Mailing Address - Country:US
Mailing Address - Phone:660-263-6642
Mailing Address - Fax:
Practice Address - Street 1:110 W SNEED ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:MO
Practice Address - Zip Code:65240-1375
Practice Address - Country:US
Practice Address - Phone:573-682-5616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty