Provider Demographics
NPI:1093024341
Name:SMILE PHOENIX PLLC
Entity Type:Organization
Organization Name:SMILE PHOENIX PLLC
Other - Org Name:SMILE FITNESS DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-362-8200
Mailing Address - Street 1:2330 N 75TH AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85035-1200
Mailing Address - Country:US
Mailing Address - Phone:623-849-0477
Mailing Address - Fax:623-849-6111
Practice Address - Street 1:2330 N 75TH AVE STE 112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-1200
Practice Address - Country:US
Practice Address - Phone:623-849-0477
Practice Address - Fax:623-849-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty