Provider Demographics
NPI:1306260401
Name:SMILES BY DR. BLACKMON
Entity type:Organization
Organization Name:SMILES BY DR. BLACKMON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-848-1420
Mailing Address - Street 1:20119 VAN AKEN BLVD STE 211
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-3636
Mailing Address - Country:US
Mailing Address - Phone:216-848-1420
Mailing Address - Fax:216-848-1400
Practice Address - Street 1:20119 VAN AKEN BLVD STE 211
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-3636
Practice Address - Country:US
Practice Address - Phone:216-848-1420
Practice Address - Fax:216-848-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0208131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2066580Medicaid