Provider Demographics
NPI:1821228347
Name:SMILES ON SEVENTH, LTD.
Entity Type:Organization
Organization Name:SMILES ON SEVENTH, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-699-1234
Mailing Address - Street 1:2390 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2800
Mailing Address - Country:US
Mailing Address - Phone:651-699-1234
Mailing Address - Fax:651-699-7715
Practice Address - Street 1:2390 7TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2800
Practice Address - Country:US
Practice Address - Phone:651-699-1234
Practice Address - Fax:651-699-7715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11243261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0316022000Medicaid
MN0316022000OtherMEDICARE