Provider Demographics
NPI:1740052802
Name:ORANGE PARK SMILES STUDIO
Entity type:Organization
Organization Name:ORANGE PARK SMILES STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CECILE
Authorized Official - Middle Name:N
Authorized Official - Last Name:LICAUCO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-984-2050
Mailing Address - Street 1:8418 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-2459
Mailing Address - Country:US
Mailing Address - Phone:714-984-2050
Mailing Address - Fax:714-984-2052
Practice Address - Street 1:8418 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-2459
Practice Address - Country:US
Practice Address - Phone:714-984-2050
Practice Address - Fax:714-984-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental