Provider Demographics
NPI:1295130292
Name:SMILES DIVINE DENTAL TMD CRANIOFACIAL PAIN CENTER
Entity type:Organization
Organization Name:SMILES DIVINE DENTAL TMD CRANIOFACIAL PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:DEPANTE
Authorized Official - Last Name:TOBIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-283-3545
Mailing Address - Street 1:6003 W THUNDERBIRD RD STE 2
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4004
Mailing Address - Country:US
Mailing Address - Phone:602-283-3545
Mailing Address - Fax:602-283-3545
Practice Address - Street 1:6003 W THUNDERBIRD RD STE 2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4004
Practice Address - Country:US
Practice Address - Phone:602-283-3545
Practice Address - Fax:602-283-3545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ53661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ559809Medicaid