Provider Demographics
NPI:1235203886
Name:KOOL SMILES P.C.
Entity Type:Organization
Organization Name:KOOL SMILES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:510-290-4744
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3227 W BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3905
Practice Address - Country:US
Practice Address - Phone:510-290-4744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC45431223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty