Provider Demographics
NPI:1962862805
Name:HAPPY SMILES OF PORT SAINT LUCIE
Entity Type:Organization
Organization Name:HAPPY SMILES OF PORT SAINT LUCIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-807-1451
Mailing Address - Street 1:1100 SW SAINT LUCIE BLVD
Mailing Address - Street 2:206
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986
Mailing Address - Country:US
Mailing Address - Phone:772-807-1451
Mailing Address - Fax:
Practice Address - Street 1:1100 SW ST LUCIE BLVD
Practice Address - Street 2:206
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1780
Practice Address - Country:US
Practice Address - Phone:772-807-1451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000800101Medicaid