Provider Demographics
NPI:1629474127
Name:SMILE GALAXY ORTHODONTICS
Entity Type:Organization
Organization Name:SMILE GALAXY ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:MOLLOY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-692-1222
Mailing Address - Street 1:PO BOX 892290
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73189-2290
Mailing Address - Country:US
Mailing Address - Phone:405-759-3724
Mailing Address - Fax:405-759-3728
Practice Address - Street 1:10001 S PENNSYLVANIA AVE BLDG P
Practice Address - Street 2:SUITE #130
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6923
Practice Address - Country:US
Practice Address - Phone:405-759-3724
Practice Address - Fax:405-759-3728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty