Provider Demographics
NPI:1801183488
Name:WORLD OF SMILES, PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:WORLD OF SMILES, PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-626-9700
Mailing Address - Street 1:11790 SW BARNES RD STE 280
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5935
Mailing Address - Country:US
Mailing Address - Phone:503-626-9700
Mailing Address - Fax:503-626-9772
Practice Address - Street 1:11790 SW BARNES RD STE 280
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5935
Practice Address - Country:US
Practice Address - Phone:503-626-9700
Practice Address - Fax:503-626-9772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD90741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1604500OtherUNITED CONCORDIA
OR218744Medicaid