Provider Demographics
NPI:1194956532
Name:SMILE ENVY FAMILY DENTISTRY, L.L.C.
Entity type:Organization
Organization Name:SMILE ENVY FAMILY DENTISTRY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIEDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:IVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-825-3689
Mailing Address - Street 1:10144 W LAKE PLEASANT PKWY
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9716
Mailing Address - Country:US
Mailing Address - Phone:623-825-3689
Mailing Address - Fax:623-825-3695
Practice Address - Street 1:10144 W LAKE PLEASANT PKWY
Practice Address - Street 2:SUITE 1100
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9716
Practice Address - Country:US
Practice Address - Phone:623-825-3689
Practice Address - Fax:623-825-3695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty