Provider Demographics
NPI:1023338597
Name:ST. CLOUD SMILES, INC.
Entity type:Organization
Organization Name:ST. CLOUD SMILES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:TRANG
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-483-8184
Mailing Address - Street 1:2050 OLD HICKORY TREE RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-8926
Mailing Address - Country:US
Mailing Address - Phone:407-556-3969
Mailing Address - Fax:
Practice Address - Street 1:2050 OLD HICKORY TREE RD
Practice Address - Street 2:SUITE J
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-8926
Practice Address - Country:US
Practice Address - Phone:407-556-3969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN180031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000333100Medicaid