Provider Demographics
NPI:1811472798
Name:CREATIVE SMILE INSTITUTE LLC
Entity type:Organization
Organization Name:CREATIVE SMILE INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED RRESENTATIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUWOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AJAGBE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:240-584-6025
Mailing Address - Street 1:1380 MONROE ST NW # 717
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-3452
Mailing Address - Country:US
Mailing Address - Phone:120-223-9710
Mailing Address - Fax:
Practice Address - Street 1:3636 16TH STREET, NW
Practice Address - Street 2:SUITE AG 13
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2001
Practice Address - Country:US
Practice Address - Phone:202-239-7108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-26
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment