Provider Demographics
NPI:1700571007
Name:SMILEBLISS BY DR. G.
Entity Type:Organization
Organization Name:SMILEBLISS BY DR. G.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:NIGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANDISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-326-2947
Mailing Address - Street 1:10117 CLEARY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324
Mailing Address - Country:US
Mailing Address - Phone:954-326-2947
Mailing Address - Fax:
Practice Address - Street 1:10117 CLEARY BOULEVARD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324
Practice Address - Country:US
Practice Address - Phone:954-326-2947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR, GRANDISON DMD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075944900Medicaid