Provider Demographics
NPI:1891553483
Name:PARKCENTER SMILES LLC
Entity Type:Organization
Organization Name:PARKCENTER SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-841-5038
Mailing Address - Street 1:2842 S HOLDEN LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5032
Mailing Address - Country:US
Mailing Address - Phone:208-841-5038
Mailing Address - Fax:
Practice Address - Street 1:600 E RIVERPARK LN STE 140
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6509
Practice Address - Country:US
Practice Address - Phone:208-841-5038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental