Provider Demographics
NPI:1346510237
Name:SMILES 4 KIDS BURLEY
Entity Type:Organization
Organization Name:SMILES 4 KIDS BURLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:GRAFF
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-734-7415
Mailing Address - Street 1:1411 FALLS AVE E
Mailing Address - Street 2:SUITE 1000C
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-734-7415
Mailing Address - Fax:208-733-1922
Practice Address - Street 1:1408 POMERELLE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2064
Practice Address - Country:US
Practice Address - Phone:208-734-7415
Practice Address - Fax:208-733-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1223P0221X1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty