Provider Demographics
NPI:1750933115
Name:SMILES OF FORT WORTH, LLC
Entity type:Organization
Organization Name:SMILES OF FORT WORTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVARADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-457-4078
Mailing Address - Street 1:PO BOX 4400
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-8400
Mailing Address - Country:US
Mailing Address - Phone:817-457-4078
Mailing Address - Fax:817-798-8912
Practice Address - Street 1:5601 BRIDGE ST STE 480
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2351
Practice Address - Country:US
Practice Address - Phone:817-457-4078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental