Provider Demographics
NPI:1912014937
Name:PEDIATRIC SMILES, INC
Entity Type:Organization
Organization Name:PEDIATRIC SMILES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:SUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-751-5126
Mailing Address - Street 1:PO BOX 26701
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-6701
Mailing Address - Country:US
Mailing Address - Phone:904-751-5126
Mailing Address - Fax:904-751-5146
Practice Address - Street 1:2262 DUNN AVE
Practice Address - Street 2:STE 4
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218
Practice Address - Country:US
Practice Address - Phone:904-751-5126
Practice Address - Fax:904-751-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 153441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL70084OtherADI HEALTHY KIDS