Provider Demographics
NPI:1316016322
Name:SMILE CENTRE PA
Entity Type:Organization
Organization Name:SMILE CENTRE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-351-4468
Mailing Address - Street 1:5899 WHITFIELD AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-6152
Mailing Address - Country:US
Mailing Address - Phone:941-351-4468
Mailing Address - Fax:941-351-9361
Practice Address - Street 1:5899 WHITFIELD AVE STE 105
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-3127
Practice Address - Country:US
Practice Address - Phone:941-351-4468
Practice Address - Fax:941-351-9361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12608122300000X
FLDN109831223G0001X, 1223G0001X
FLDN160791223G0001X
FLDH6360124Q00000X
FLDH15541124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty