Provider Demographics
NPI:1619308566
Name:KIDS SMILE INNOVATIONS LLC
Entity Type:Organization
Organization Name:KIDS SMILE INNOVATIONS LLC
Other - Org Name:THE KID'S SMILE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPIVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:767-617-4750
Mailing Address - Street 1:110 SUMMERS DR
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-8696
Mailing Address - Country:US
Mailing Address - Phone:765-617-4750
Mailing Address - Fax:
Practice Address - Street 1:5129 CLINTON DR
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-7136
Practice Address - Country:US
Practice Address - Phone:765-617-4750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008126A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty