Provider Demographics
NPI:1265846596
Name:SMILE TEC
Entity Type:Organization
Organization Name:SMILE TEC
Other - Org Name:HUBBARD FAMILY DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTAL HYGIENIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:MARGUERITE
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:970-301-1363
Mailing Address - Street 1:5207 W B ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4269
Mailing Address - Country:US
Mailing Address - Phone:970-301-1363
Mailing Address - Fax:
Practice Address - Street 1:5207 W B ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4269
Practice Address - Country:US
Practice Address - Phone:970-301-1363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-14
Last Update Date:2014-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905326302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO970072214Medicaid