Provider Demographics
NPI:1033814710
Name:SMILE SALON, PLLC
Entity Type:Organization
Organization Name:SMILE SALON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:408-221-9128
Mailing Address - Street 1:1600 S 1ST ST STE 160
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-3048
Mailing Address - Country:US
Mailing Address - Phone:512-653-4009
Mailing Address - Fax:
Practice Address - Street 1:1600 S 1ST ST STE 160
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-3048
Practice Address - Country:US
Practice Address - Phone:512-653-4009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental