Provider Demographics
NPI:1871002261
Name:SMILE NINJA, PLLC
Entity type:Organization
Organization Name:SMILE NINJA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-916-4431
Mailing Address - Street 1:220 E SEMINARY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-2653
Mailing Address - Country:US
Mailing Address - Phone:817-916-4431
Mailing Address - Fax:
Practice Address - Street 1:220 E SEMINARY DR STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-2653
Practice Address - Country:US
Practice Address - Phone:817-916-4431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty