Basic Information
Provider Information | |||||||||
NPI: | 1073684247 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GARY SMILES YOUTH DENTISTRY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16 ARCADE UNIT 198747 | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372191994 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6157500343 | ||||||||
FaxNumber: | 6159861705 | ||||||||
Practice Location | |||||||||
Address1: | 3506 VILLAGE CT | ||||||||
Address2: |   | ||||||||
City: | GARY | ||||||||
State: | IN | ||||||||
PostalCode: | 464081428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2199853133 | ||||||||
FaxNumber: | 2199853139 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2006 | ||||||||
LastUpdateDate: | 07/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STUMP | ||||||||
AuthorizedOfficialFirstName: | JENELL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER, LICENSING & CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 6157500343 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 1073684247 | 05 | IL |   | MEDICAID | 200379630A | 05 | IN |   | MEDICAID |