Provider Demographics
NPI:1386354751
Name:PEORIA DENTAL SMILES LLC
Entity type:Organization
Organization Name:PEORIA DENTAL SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:TERA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEDENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-289-2616
Mailing Address - Street 1:34225 N 27TH DR STE 241
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6091
Mailing Address - Country:US
Mailing Address - Phone:623-289-2616
Mailing Address - Fax:
Practice Address - Street 1:9059 W LAKE PLEASANT PKWY STE A100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8393
Practice Address - Country:US
Practice Address - Phone:623-572-0102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental