Provider Demographics
NPI:1871754978
Name:KIDS SMILE, PC
Entity type:Organization
Organization Name:KIDS SMILE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURICIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCUSHAMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-225-8888
Mailing Address - Street 1:315 N SAN SABA
Mailing Address - Street 2:SUITE#1220
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3154
Mailing Address - Country:US
Mailing Address - Phone:210-225-8888
Mailing Address - Fax:210-225-4195
Practice Address - Street 1:315 N SAN SABA
Practice Address - Street 2:SUITE #1220
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3154
Practice Address - Country:US
Practice Address - Phone:210-225-8888
Practice Address - Fax:210-225-4195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX185801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1209389-02Medicaid