Provider Demographics
NPI:1235329210
Name:MILES OF SMILES VENTURES, LLC
Entity Type:Organization
Organization Name:MILES OF SMILES VENTURES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-639-3515
Mailing Address - Street 1:4040 N. MARTIN LUTHER KING
Mailing Address - Street 2:STE B.
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-3205
Mailing Address - Country:US
Mailing Address - Phone:702-639-3515
Mailing Address - Fax:702-639-3516
Practice Address - Street 1:4040 N. MARTIN LUTHER KING
Practice Address - Street 2:STE B.
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-3205
Practice Address - Country:US
Practice Address - Phone:702-639-3515
Practice Address - Fax:702-639-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4522T122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506669Medicaid
NV100502976Medicaid