Provider Demographics
NPI:1235427485
Name:AMAZING SMILES STUDIO ORTHODONTICS
Entity Type:Organization
Organization Name:AMAZING SMILES STUDIO ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:N
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:919-360-0607
Mailing Address - Street 1:4000 VICTORIA PARK DR APT 4101
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-3200
Mailing Address - Country:US
Mailing Address - Phone:919-360-0607
Mailing Address - Fax:
Practice Address - Street 1:4000 VICTORIA PARK DR APT 4101
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-3200
Practice Address - Country:US
Practice Address - Phone:919-360-0607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN183621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty