Provider Demographics
NPI:1578687588
Name:POWER SMILES
Entity Type:Organization
Organization Name:POWER SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-641-4633
Mailing Address - Street 1:1914 S POWER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4376
Mailing Address - Country:US
Mailing Address - Phone:480-641-4633
Mailing Address - Fax:480-641-9432
Practice Address - Street 1:1914 S POWER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4376
Practice Address - Country:US
Practice Address - Phone:480-641-4633
Practice Address - Fax:480-641-9432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5282122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty