1366916892 NPI number — LITTLE SMILE COMPANY

Table of content: (NPI 1366916892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366916892 NPI number — LITTLE SMILE COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE SMILE COMPANY
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:
LITTLE SMILE CO. PEDIATRIC DENTISTRY & ORTHODONTICS
Provider Other Organization Name Type Code:
3
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:
1366916892
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 S CHRISMAN AVE # 730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38732-3316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-801-6183
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38732-2358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-843-0000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
ROENIKYA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ PEDIATRIC DENTIST
Authorized Official Telephone Number:
662-801-6861

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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