Provider Demographics
NPI:1679026264
Name:KOOL SMILES
Entity Type:Organization
Organization Name:KOOL SMILES
Other - Org Name:UAB HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-285-4807
Mailing Address - Street 1:3719 JEWELLA AVE,
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109
Mailing Address - Country:US
Mailing Address - Phone:318-573-9918
Mailing Address - Fax:
Practice Address - Street 1:3719 JEWELLA AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-4703
Practice Address - Country:US
Practice Address - Phone:318-759-0905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6698122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty