Provider Demographics
NPI:1508624339
Name:ADMIRE YOUR SMILE LLC
Entity Type:Organization
Organization Name:ADMIRE YOUR SMILE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:620-240-0565
Mailing Address - Street 1:1600 SOUTHWEST BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109
Mailing Address - Country:US
Mailing Address - Phone:573-635-4852
Mailing Address - Fax:573-635-1167
Practice Address - Street 1:1600 B SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-635-4852
Practice Address - Fax:573-635-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty