Provider Demographics
NPI:1619237633
Name:OUTREACH FOR SMILES OF COLORADO, PLLC
Entity type:Organization
Organization Name:OUTREACH FOR SMILES OF COLORADO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAN MIGUEL
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:210-412-5798
Mailing Address - Street 1:8519 COLLINGWOOD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-2849
Mailing Address - Country:US
Mailing Address - Phone:210-412-5798
Mailing Address - Fax:
Practice Address - Street 1:8519 COLLINGWOOD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-2849
Practice Address - Country:US
Practice Address - Phone:210-412-5798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO906556124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty