Provider Demographics
NPI:1134673932
Name:SLD LLC
Entity Type:Organization
Organization Name:SLD LLC
Other - Org Name:SMILE LINES DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-332-6111
Mailing Address - Street 1:4146 NEUMAN RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-3234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21300 N JOHN WAYNE PKWY
Practice Address - Street 2:STE 108
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-8979
Practice Address - Country:US
Practice Address - Phone:520-494-7578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD056251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty