1619691896 NPI number — SMILEY DENTAL WICHITA FALLS PLLC

Table of content: (NPI 1619691896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619691896 NPI number — SMILEY DENTAL WICHITA FALLS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILEY DENTAL WICHITA FALLS PLLC
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:
1619691896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 450758
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75045-0758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-902-6792
Provider Business Mailing Address Fax Number:
214-367-5896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1211 LOOP 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76306-6800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-855-3435
Provider Business Practice Location Address Fax Number:
940-855-3835
Provider Enumeration Date:
09/30/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
LYNHTHY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
469-902-6792

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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