Provider Demographics
NPI:1225709074
Name:SMILE STRAIGHT ORTHODONTICS - JACKSON LLC
Entity Type:Organization
Organization Name:SMILE STRAIGHT ORTHODONTICS - JACKSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:ZWICKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-866-8811
Mailing Address - Street 1:5717 E THOMAS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-7620
Mailing Address - Country:US
Mailing Address - Phone:480-866-8811
Mailing Address - Fax:602-429-8200
Practice Address - Street 1:310 W WOODROW WILSON AVE STE 400
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7697
Practice Address - Country:US
Practice Address - Phone:769-230-1940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty