Provider Demographics
NPI:1578721106
Name:SMILES FOR COLORADO ORTHODONTICS, PC
Entity Type:Organization
Organization Name:SMILES FOR COLORADO ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BANGORN
Authorized Official - Middle Name:S
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, DMD
Authorized Official - Phone:719-227-7645
Mailing Address - Street 1:8115 NIGHT BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-3300
Mailing Address - Country:US
Mailing Address - Phone:210-264-3102
Mailing Address - Fax:
Practice Address - Street 1:1539 S 8TH ST STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-1977
Practice Address - Country:US
Practice Address - Phone:719-227-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO99488361Medicaid