Provider Demographics
NPI:1205249943
Name:SMILEMAKERS, PLLC
Entity type:Organization
Organization Name:SMILEMAKERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-734-7246
Mailing Address - Street 1:142 RIVER VISTA PL
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 RIVER VISTA PL
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3056
Practice Address - Country:US
Practice Address - Phone:208-734-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4353-PR335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20004358OtherMEDICARE PTAN