Provider Demographics
NPI:1366711087
Name:PEDIATRIC SMILES PLLC
Entity type:Organization
Organization Name:PEDIATRIC SMILES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:1801-224-0861
Mailing Address - Street 1:167 N 400 W
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-1909
Mailing Address - Country:US
Mailing Address - Phone:801-224-0861
Mailing Address - Fax:801-804-5899
Practice Address - Street 1:167 N 400 W
Practice Address - Street 2:SUITE A-4
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1909
Practice Address - Country:US
Practice Address - Phone:801-224-0861
Practice Address - Fax:801-804-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT80123191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty