Provider Demographics
NPI:1356096507
Name:SMILE FX
Entity Type:Organization
Organization Name:SMILE FX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEQUILLANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-545-8226
Mailing Address - Street 1:6919 W. FOREST HOME AVE.
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220
Mailing Address - Country:US
Mailing Address - Phone:414-545-8226
Mailing Address - Fax:414-543-4805
Practice Address - Street 1:6919 W. FOREST HOME AVE.
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220
Practice Address - Country:US
Practice Address - Phone:414-545-8226
Practice Address - Fax:414-543-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty