Provider Demographics
NPI:1598131625
Name:SMILE STUDIO OF CLAREMORE LLC
Entity Type:Organization
Organization Name:SMILE STUDIO OF CLAREMORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HARROZ
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-737-5905
Mailing Address - Street 1:PO BOX 30466
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73140-3466
Mailing Address - Country:US
Mailing Address - Phone:405-737-5905
Mailing Address - Fax:
Practice Address - Street 1:5103 N SHARTEL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-6049
Practice Address - Country:US
Practice Address - Phone:405-737-5905
Practice Address - Fax:405-739-0328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200208520AMedicaid