Basic Information
| Provider Information | |||||||||
| NPI: | 1184741704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMALL SMILES OF BEAUMONT, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195831800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3865 PHELAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777072243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195831800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | KALLENE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7195831800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.