Provider Demographics
NPI:1013598739
Name:IMAGINE SMILES PLLC
Entity type:Organization
Organization Name:IMAGINE SMILES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THAO
Authorized Official - Middle Name:
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-906-6179
Mailing Address - Street 1:5259 ARIVA DR APT 101
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4436
Mailing Address - Country:US
Mailing Address - Phone:864-906-6179
Mailing Address - Fax:
Practice Address - Street 1:13205 REAMS RD UNIT 164
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786
Practice Address - Country:US
Practice Address - Phone:864-906-6179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty