Provider Demographics
NPI:1114753837
Name:FULL SMILE EASTERN FAMILY DENTISTRY, PLLC
Entity type:Organization
Organization Name:FULL SMILE EASTERN FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:AMES
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-353-1055
Mailing Address - Street 1:2201 CIVIC CIR STE 600
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1817
Mailing Address - Country:US
Mailing Address - Phone:806-353-1055
Mailing Address - Fax:
Practice Address - Street 1:1521 W 18TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-7018
Practice Address - Country:US
Practice Address - Phone:806-353-1055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental