Provider Demographics
NPI:1356716997
Name:SMILE DENTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:SMILE DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:660-263-6642
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-0306
Mailing Address - Country:US
Mailing Address - Phone:660-263-6642
Mailing Address - Fax:
Practice Address - Street 1:1620 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2478
Practice Address - Country:US
Practice Address - Phone:660-263-6642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110150341223G0001X
MO0133221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty