Provider Demographics
NPI:1033661848
Name:KIDS SMILES DENTAL, PLLC
Entity Type:Organization
Organization Name:KIDS SMILES DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:NEELY
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-968-2483
Mailing Address - Street 1:1773 W FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-1820
Mailing Address - Country:US
Mailing Address - Phone:813-968-2483
Mailing Address - Fax:
Practice Address - Street 1:1773 W FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-968-2483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDS SMILES PARTNERS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-27
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN132851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017306300Medicaid
FL075109000Medicaid