Provider Demographics
NPI:1699176073
Name:FABULOUS SMILES ORTHODONTICS, LLC
Entity Type:Organization
Organization Name:FABULOUS SMILES ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-258-1876
Mailing Address - Street 1:3101 W INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-4035
Mailing Address - Country:US
Mailing Address - Phone:602-861-3333
Mailing Address - Fax:602-682-7733
Practice Address - Street 1:3101 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4035
Practice Address - Country:US
Practice Address - Phone:602-861-3333
Practice Address - Fax:602-682-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD75171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty