Provider Demographics
NPI:1861650368
Name:THE SMILE STUDIO PA
Entity type:Organization
Organization Name:THE SMILE STUDIO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:O
Authorized Official - Last Name:RIVES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-605-2525
Mailing Address - Street 1:1029 HIGHWAY 51 STE D
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7648
Mailing Address - Country:US
Mailing Address - Phone:601-605-2525
Mailing Address - Fax:601-605-2524
Practice Address - Street 1:1029 HIGHWAY 51 STE D
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7648
Practice Address - Country:US
Practice Address - Phone:601-605-2525
Practice Address - Fax:601-605-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3207011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06684372Medicaid