Provider Demographics
NPI:1154799047
Name:SMILES 4 KIDS BLACKFOOT PLLC
Entity type:Organization
Organization Name:SMILES 4 KIDS BLACKFOOT PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-529-3007
Mailing Address - Street 1:621 JENSEN GROVE DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1685
Mailing Address - Country:US
Mailing Address - Phone:208-785-4696
Mailing Address - Fax:
Practice Address - Street 1:621 JENSEN GROVE DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1685
Practice Address - Country:US
Practice Address - Phone:208-785-4696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty