Provider Demographics
NPI:1235976747
Name:MO SMILES LLC
Entity type:Organization
Organization Name:MO SMILES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:CANDELAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-582-4157
Mailing Address - Street 1:7200 W BELL RD STE E102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7200 W BELL RD STE E102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8534
Practice Address - Country:US
Practice Address - Phone:623-934-9191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty