Provider Demographics
NPI:1871369298
Name:THE SMILE FACTORY MOBILE CLINIC LLC
Entity type:Organization
Organization Name:THE SMILE FACTORY MOBILE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERONTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-606-7824
Mailing Address - Street 1:1040 CARLYLE AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5533
Mailing Address - Country:US
Mailing Address - Phone:618-606-7824
Mailing Address - Fax:
Practice Address - Street 1:1040 CARLYLE AVE STE 2A
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5533
Practice Address - Country:US
Practice Address - Phone:618-606-7824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty