Provider Demographics
NPI:1235730953
Name:SPARKLING SMILES MOBILE DENTISTRY LLC
Entity Type:Organization
Organization Name:SPARKLING SMILES MOBILE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDH
Authorized Official - Prefix:
Authorized Official - First Name:KASSIDEE
Authorized Official - Middle Name:N
Authorized Official - Last Name:FICKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-630-4226
Mailing Address - Street 1:7525 COUNTY ROAD M
Mailing Address - Street 2:
Mailing Address - City:KIRK
Mailing Address - State:CO
Mailing Address - Zip Code:80824-9759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6671 US HWY 36
Practice Address - Street 2:
Practice Address - City:JOES
Practice Address - State:CO
Practice Address - Zip Code:80822
Practice Address - Country:US
Practice Address - Phone:970-630-4226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty