Provider Demographics
NPI:1558964536
Name:FULL SMILE DENTAL, PLLC
Entity Type:Organization
Organization Name:FULL SMILE DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-418-9924
Mailing Address - Street 1:5051 S SONCY RD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6667
Mailing Address - Country:US
Mailing Address - Phone:806-353-1055
Mailing Address - Fax:806-353-7077
Practice Address - Street 1:816 AVENUE A
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:TX
Practice Address - Zip Code:79325
Practice Address - Country:US
Practice Address - Phone:806-353-1055
Practice Address - Fax:806-353-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty