Provider Demographics
NPI:1225274087
Name:KIDS LITTLE SMILES DENTISTRY
Entity Type:Organization
Organization Name:KIDS LITTLE SMILES DENTISTRY
Other - Org Name:KIDS LITTLE SMILES DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-718-7645
Mailing Address - Street 1:2202 HUALAPAI MOUNTAIN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-8337
Mailing Address - Country:US
Mailing Address - Phone:928-718-7645
Mailing Address - Fax:928-718-7655
Practice Address - Street 1:2202 HUALAPAI MOUNTAIN RD STE 201
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-8337
Practice Address - Country:US
Practice Address - Phone:928-718-7645
Practice Address - Fax:928-718-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD46881223G0001X
AZD55801223G0001X
AZD75821223G0001X
AZD54321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty