Provider Demographics
NPI:1386274777
Name:CRESTVIEW SMILES, PA
Entity type:Organization
Organization Name:CRESTVIEW SMILES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-699-6111
Mailing Address - Street 1:4400 E HIGHWAY 20 STE 101
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-9735
Mailing Address - Country:US
Mailing Address - Phone:850-897-4488
Mailing Address - Fax:850-897-1446
Practice Address - Street 1:5170 S FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-9258
Practice Address - Country:US
Practice Address - Phone:850-897-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental