Provider Demographics
NPI:1336755362
Name:HEAVENLY SMILES MOBILE DENTAL
Entity Type:Organization
Organization Name:HEAVENLY SMILES MOBILE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSSWHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-806-4786
Mailing Address - Street 1:6337 HAWTHORN WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-1389
Mailing Address - Country:US
Mailing Address - Phone:702-445-1060
Mailing Address - Fax:
Practice Address - Street 1:6337 HAWTHORN WOODS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-1389
Practice Address - Country:US
Practice Address - Phone:702-445-1060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250008207Medicaid