Provider Demographics
NPI:1952189136
Name:SIMPLE MIRACLES DENTISTRY, LLC
Entity Type:Organization
Organization Name:SIMPLE MIRACLES DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-383-0958
Mailing Address - Street 1:16900 SCIENCE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4465
Mailing Address - Country:US
Mailing Address - Phone:301-383-0958
Mailing Address - Fax:240-487-5161
Practice Address - Street 1:16900 SCIENCE DR STE 110
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4465
Practice Address - Country:US
Practice Address - Phone:301-383-0958
Practice Address - Fax:240-487-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty