Provider Demographics
NPI:1417403718
Name:MOBILE SMILES P.A. LLC
Entity Type:Organization
Organization Name:MOBILE SMILES P.A. LLC
Other - Org Name:SMILES EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-759-1020
Mailing Address - Street 1:5868 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4075
Mailing Address - Country:US
Mailing Address - Phone:317-759-1020
Mailing Address - Fax:
Practice Address - Street 1:5868 E. 71ST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4002
Practice Address - Country:US
Practice Address - Phone:317-759-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009992122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty