Provider Demographics
NPI:1639472673
Name:WILD SMILES PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:WILD SMILES PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:731-286-1271
Mailing Address - Street 1:1189 VANN DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305
Mailing Address - Country:US
Mailing Address - Phone:731-300-0386
Mailing Address - Fax:731-300-0519
Practice Address - Street 1:1189 VANN DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-286-1271
Practice Address - Fax:731-286-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty