Provider Demographics
NPI:1487941860
Name:THE SMILE SPA
Entity type:Organization
Organization Name:THE SMILE SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-755-0001
Mailing Address - Street 1:8110 CORDOVA RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0520
Mailing Address - Country:US
Mailing Address - Phone:901-755-0001
Mailing Address - Fax:901-755-9679
Practice Address - Street 1:8110 CORDOVA RD
Practice Address - Street 2:SUITE 125
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0520
Practice Address - Country:US
Practice Address - Phone:901-755-0001
Practice Address - Fax:901-755-9679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN74811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1520260Medicaid