Provider Demographics
NPI:1598000325
Name:SMILE STUDIO OF WYLIE, PLLC
Entity Type:Organization
Organization Name:SMILE STUDIO OF WYLIE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-442-3028
Mailing Address - Street 1:1125 W FM 544
Mailing Address - Street 2:STE. 700
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-4951
Mailing Address - Country:US
Mailing Address - Phone:972-442-3028
Mailing Address - Fax:972-442-3831
Practice Address - Street 1:1125 W FM 544
Practice Address - Street 2:STE 700
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-4951
Practice Address - Country:US
Practice Address - Phone:972-442-3028
Practice Address - Fax:972-442-3831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19412122300000X
TX24605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty