Provider Demographics
NPI:1295149334
Name:SMILES DENTAL GROUP, PC
Entity type:Organization
Organization Name:SMILES DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, MBA
Authorized Official - Phone:206-919-6578
Mailing Address - Street 1:820 OCEAN BEACH HWY
Mailing Address - Street 2:STE 110
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4080
Mailing Address - Country:US
Mailing Address - Phone:503-981-1841
Mailing Address - Fax:503-981-7334
Practice Address - Street 1:1018 N BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9602
Practice Address - Country:US
Practice Address - Phone:503-981-1841
Practice Address - Fax:503-981-7334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8230332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment