Provider Demographics
NPI:1598115644
Name:TEN MILE SMILES INC
Entity Type:Organization
Organization Name:TEN MILE SMILES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-887-9000
Mailing Address - Street 1:2700 W CHERRY LN
Mailing Address - Street 2:STE 120
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1500
Mailing Address - Country:US
Mailing Address - Phone:208-887-9000
Mailing Address - Fax:208-887-9107
Practice Address - Street 1:2700 W CHERRY LN
Practice Address - Street 2:STE 120
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1500
Practice Address - Country:US
Practice Address - Phone:208-887-9000
Practice Address - Fax:208-887-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-47211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1235336827OtherNPI
ID1568535011OtherNPI