Provider Demographics
NPI:1710010285
Name:FAMILY SMILES DENTISTRY, PLLC
Entity type:Organization
Organization Name:FAMILY SMILES DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:CLOTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-251-3333
Mailing Address - Street 1:16534 E 49TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-7190
Mailing Address - Country:US
Mailing Address - Phone:918-251-8999
Mailing Address - Fax:
Practice Address - Street 1:300 N ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2205
Practice Address - Country:US
Practice Address - Phone:918-251-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty