Provider Demographics
NPI:1184986077
Name:ALL ABOUT SMILES LC
Entity type:Organization
Organization Name:ALL ABOUT SMILES LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LORIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:VAN DRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-234-3305
Mailing Address - Street 1:1717 E CHEROKEE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2335
Mailing Address - Country:US
Mailing Address - Phone:417-889-5757
Mailing Address - Fax:417-889-5758
Practice Address - Street 1:1717 E CHEROKEE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2335
Practice Address - Country:US
Practice Address - Phone:417-889-5757
Practice Address - Fax:417-889-5758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO012493261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1841511805Medicaid
MO1669574935Medicaid