Provider Demographics
NPI:1689024465
Name:SMILE STATION FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:SMILE STATION FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-519-7342
Mailing Address - Street 1:710 WINDSOR WOODS
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4676
Mailing Address - Country:US
Mailing Address - Phone:270-408-1234
Mailing Address - Fax:
Practice Address - Street 1:5504 REIDLAND RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-0955
Practice Address - Country:US
Practice Address - Phone:270-408-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7956122300000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentistGroup - Single Specialty