Provider Demographics
NPI:1881302586
Name:GREAT SMILES DENTAL GROUP LLC
Entity type:Organization
Organization Name:GREAT SMILES DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:TERA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEDENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-289-2616
Mailing Address - Street 1:34225 N 27TH DR STE 241
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6091
Mailing Address - Country:US
Mailing Address - Phone:623-289-2616
Mailing Address - Fax:
Practice Address - Street 1:14800 W MOUNTAIN VIEW BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2703
Practice Address - Country:US
Practice Address - Phone:623-933-5749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental