Provider Demographics
NPI:1689072233
Name:SMILE CENTER FOR KIDS I PLLC
Entity Type:Organization
Organization Name:SMILE CENTER FOR KIDS I PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-493-6310
Mailing Address - Street 1:12801 EDGEMERE BLVD # B
Mailing Address - Street 2:SUITE 112
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-9500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 SUNDLAND PARK DRIVE
Practice Address - Street 2:SUITE 200 B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79922
Practice Address - Country:US
Practice Address - Phone:915-493-6310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
TX24420261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty