Provider Demographics
NPI:1871772764
Name:DIVINE SMILES DENTAL STUDIOS, INC.
Entity type:Organization
Organization Name:DIVINE SMILES DENTAL STUDIOS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-254-0200
Mailing Address - Street 1:620 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3434
Mailing Address - Country:US
Mailing Address - Phone:479-986-0200
Mailing Address - Fax:
Practice Address - Street 1:620 N 13TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3434
Practice Address - Country:US
Practice Address - Phone:479-986-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental