Provider Demographics
NPI:1508815747
Name:SMALL SMILES OF RENO, LLC
Entity Type:Organization
Organization Name:SMALL SMILES OF RENO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST/LEAD
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:775-329-5437
Mailing Address - Street 1:3362 S. MCCARRAN BLVD.
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502
Mailing Address - Country:US
Mailing Address - Phone:775-329-5437
Mailing Address - Fax:775-829-1553
Practice Address - Street 1:3362 S. MCCARRAN BLVD.
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502
Practice Address - Country:US
Practice Address - Phone:775-329-5437
Practice Address - Fax:775-829-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
NV1223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1508815747Medicaid