Provider Demographics
NPI:1174133698
Name:IMAGINE SMILES
Entity type:Organization
Organization Name:IMAGINE SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-269-8650
Mailing Address - Street 1:10729 TOWN SQUARE DRIVE NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449
Mailing Address - Country:US
Mailing Address - Phone:763-269-8650
Mailing Address - Fax:763-201-3377
Practice Address - Street 1:10729 TOWN SQUARE DRIVE NE
Practice Address - Street 2:SUITE 150
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449
Practice Address - Country:US
Practice Address - Phone:763-269-8650
Practice Address - Fax:763-201-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental