1407128663 NPI number — SMILES FOR KIDS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407128663 NPI number — SMILES FOR KIDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILES FOR KIDS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407128663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5140 BEECHAM CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUWANEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30024-3390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-433-1317
Provider Business Mailing Address Fax Number:
770-781-0204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1240 BUFORD RD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30041-2731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-781-0203
Provider Business Practice Location Address Fax Number:
770-781-0204
Provider Enumeration Date:
02/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SHARMA
Authorized Official First Name:
JYOTI
Authorized Official Middle Name:
DESH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-433-1317

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  DN12806 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 437813642M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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