Provider Demographics
NPI:1821162470
Name:WILD FOR A SMILE
Entity Type:Organization
Organization Name:WILD FOR A SMILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:MISCHELLE
Authorized Official - Last Name:DOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-506-1339
Mailing Address - Street 1:1819 61ST AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7986
Mailing Address - Country:US
Mailing Address - Phone:970-506-1339
Mailing Address - Fax:970-339-8500
Practice Address - Street 1:1819 61ST AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-7986
Practice Address - Country:US
Practice Address - Phone:970-506-1339
Practice Address - Fax:970-339-8500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO85261223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty