Provider Demographics
NPI:1528701463
Name:SMILES OF PUNTA GORDA, PA
Entity type:Organization
Organization Name:SMILES OF PUNTA GORDA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:VICENTA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:100 MADRID BLVD UNIT 414
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-8929
Mailing Address - Country:US
Mailing Address - Phone:941-575-2626
Mailing Address - Fax:
Practice Address - Street 1:100 MADRID BLVD UNIT 414
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-8929
Practice Address - Country:US
Practice Address - Phone:941-575-2626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty