Provider Demographics
NPI:1023314564
Name:SMILE DESIGN DENTISTRY, PLLC
Entity type:Organization
Organization Name:SMILE DESIGN DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-537-1238
Mailing Address - Street 1:3475 PLYMOUTH BLVD
Mailing Address - Street 2:100
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1499
Mailing Address - Country:US
Mailing Address - Phone:763-537-1238
Mailing Address - Fax:763-537-4627
Practice Address - Street 1:3475 PLYMOUTH BLVD
Practice Address - Street 2:100
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1499
Practice Address - Country:US
Practice Address - Phone:763-537-1238
Practice Address - Fax:763-537-4627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty