Provider Demographics
NPI:1346516929
Name:SMILES 4 KIDS, LLC
Entity Type:Organization
Organization Name:SMILES 4 KIDS, LLC
Other - Org Name:SMILES 4 KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-247-0174
Mailing Address - Street 1:4337 E MAIN ST
Mailing Address - Street 2:STE 205
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4337 E MAIN ST
Practice Address - Street 2:STE 205
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-8633
Practice Address - Country:US
Practice Address - Phone:970-247-0202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty