Provider Demographics
NPI:1144416959
Name:LIFESMILE DENTAL GROUP
Entity Type:Organization
Organization Name:LIFESMILE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-644-5433
Mailing Address - Street 1:13305 NW CORNELL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5817
Mailing Address - Country:US
Mailing Address - Phone:503-644-5433
Mailing Address - Fax:503-633-5436
Practice Address - Street 1:13305 NW CORNELL RD
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5817
Practice Address - Country:US
Practice Address - Phone:503-644-5433
Practice Address - Fax:503-633-5436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-15
Last Update Date:2007-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty