Provider Demographics
NPI:1063120343
Name:FULL SMILE DENTAL HEREFORD, PLLC
Entity type:Organization
Organization Name:FULL SMILE DENTAL HEREFORD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CS
Authorized Official - Phone:806-353-1055
Mailing Address - Street 1:5051 S SONCY RD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6667
Mailing Address - Country:US
Mailing Address - Phone:806-353-1055
Mailing Address - Fax:806-353-7077
Practice Address - Street 1:809 W PARK AVE
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:TX
Practice Address - Zip Code:79045-4001
Practice Address - Country:US
Practice Address - Phone:806-641-1373
Practice Address - Fax:806-353-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty