Provider Demographics
NPI:1932642634
Name:ULTIMATE SMILE DESIGN LLC
Entity Type:Organization
Organization Name:ULTIMATE SMILE DESIGN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-984-7878
Mailing Address - Street 1:730 EMERSON DR NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1430
Mailing Address - Country:US
Mailing Address - Phone:321-984-7878
Mailing Address - Fax:
Practice Address - Street 1:730 EMERSON DR NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1430
Practice Address - Country:US
Practice Address - Phone:321-984-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ULTIMATE SMILE DESIGN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10353122300000X
FLDN207991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty