Provider Demographics
NPI:1114387982
Name:SMILES DENTAL GROUP, PC
Entity Type:Organization
Organization Name:SMILES DENTAL GROUP, PC
Other - Org Name:SMILES DENTAL GROUP, PC AK
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF DENTAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-261-6094
Mailing Address - Street 1:900 FIR ST
Mailing Address - Street 2:1D
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2544
Mailing Address - Country:US
Mailing Address - Phone:360-261-6094
Mailing Address - Fax:
Practice Address - Street 1:9138 ARLON ST
Practice Address - Street 2:SUITE B1
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-3876
Practice Address - Country:US
Practice Address - Phone:360-261-6094
Practice Address - Fax:360-423-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122400000XDental ProvidersDenturistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
No126800000XDental ProvidersDental AssistantGroup - Single Specialty