Provider Demographics
NPI:1437369105
Name:SMILE DESIGN FAMILY DENTISTRY
Entity type:Organization
Organization Name:SMILE DESIGN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-454-4771
Mailing Address - Street 1:1121 TOWN CENTRE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1217
Mailing Address - Country:US
Mailing Address - Phone:651-454-4771
Mailing Address - Fax:
Practice Address - Street 1:1121 TOWN CENTRE DR STE 200
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1217
Practice Address - Country:US
Practice Address - Phone:651-454-4771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9788122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty