Provider Demographics
NPI:1568184612
Name:INNOVATIVE SMILE MAKERS LLC
Entity Type:Organization
Organization Name:INNOVATIVE SMILE MAKERS LLC
Other - Org Name:POWER SMILES DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:LAUREN
Authorized Official - Last Name:HERR
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-580-1499
Mailing Address - Street 1:8490 S POWER RD STE 106
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-8029
Mailing Address - Country:US
Mailing Address - Phone:480-580-1499
Mailing Address - Fax:480-580-1788
Practice Address - Street 1:8490 S POWER RD STE 106
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-8029
Practice Address - Country:US
Practice Address - Phone:480-580-1499
Practice Address - Fax:480-580-1788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-15
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty