Provider Demographics
NPI:1528250412
Name:SMILENEEDS DENTAL
Entity type:Organization
Organization Name:SMILENEEDS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-466-1245
Mailing Address - Street 1:1183 E FOOTHILL BLVD
Mailing Address - Street 2:SUITE150
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4079
Mailing Address - Country:US
Mailing Address - Phone:909-466-1245
Mailing Address - Fax:909-912-8245
Practice Address - Street 1:1183 E FOOTHILL BLVD
Practice Address - Street 2:SUITE150
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4079
Practice Address - Country:US
Practice Address - Phone:909-466-1245
Practice Address - Fax:909-912-8245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD43911-01Medicaid