Provider Demographics
NPI:1770758765
Name:SAN TAN RANCH SMILES LLC
Entity type:Organization
Organization Name:SAN TAN RANCH SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-292-3598
Mailing Address - Street 1:3592 S ATHERTON BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7443
Mailing Address - Country:US
Mailing Address - Phone:480-457-8600
Mailing Address - Fax:
Practice Address - Street 1:3592 S ATHERTON BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7443
Practice Address - Country:US
Practice Address - Phone:480-457-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty