Provider Demographics
NPI:1952815003
Name:SMILE DENTAL PLLC
Entity Type:Organization
Organization Name:SMILE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDISCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-319-2440
Mailing Address - Street 1:9491 CEDAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-7517
Mailing Address - Country:US
Mailing Address - Phone:954-649-5588
Mailing Address - Fax:954-649-5588
Practice Address - Street 1:9500 BONITA BEACH RD SE STE 301
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4698
Practice Address - Country:US
Practice Address - Phone:239-319-2440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1114280245OtherNPI
FL1326298753OtherNPI