Provider Demographics
NPI:1629578539
Name:THE SMILE STORE, LLC
Entity Type:Organization
Organization Name:THE SMILE STORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:CUNNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:833-900-1050
Mailing Address - Street 1:9597 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2424
Mailing Address - Country:US
Mailing Address - Phone:833-900-1050
Mailing Address - Fax:833-200-5256
Practice Address - Street 1:740 AVENUE H STE 2
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-6619
Practice Address - Country:US
Practice Address - Phone:503-738-1860
Practice Address - Fax:833-200-5256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDT-DO10130609OtherOREGON STATE DEPARTMENT OF HEALTH
WADN-60139787OtherWASHINGTON STATE DEPARTMENT OF HEALTH