Provider Demographics
NPI:1760755169
Name:SMILING CREATIONS, PA
Entity Type:Organization
Organization Name:SMILING CREATIONS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-284-6688
Mailing Address - Street 1:708 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3318
Mailing Address - Country:US
Mailing Address - Phone:904-284-6688
Mailing Address - Fax:
Practice Address - Street 1:708 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-3318
Practice Address - Country:US
Practice Address - Phone:904-284-6688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00109811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072874800Medicaid