# CREATE-A-SMILE, PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1588995229
- **Authorized official:** DR. SHANNON KENNETH MOORE DMD, MSED (OWNER)
- **Authorized official phone:** (812) 332-1405

## Contact information

- **Practice address:** 2815 N WALNUT ST, BLOOMINGTON, IN 47404-2077
- **Practice address phone:** (812) 332-1405
- **Practice address fax:** (812) 332-4331
- **Mailing address:** 2815 N WALNUT ST, BLOOMINGTON, IN 47404-2077
- **Mailing address phone:** (812) 332-1405
- **Mailing address fax:** (812) 332-4331

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 12010311A | IN | Yes |
| 122300000X | Dentist | 12011246A | IN | — |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | — | — |

## Other

- **Enumeration date:** 01/20/2010
- **Last updated:** 05/17/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1194855205 | NPI | IN |
| 05 | — | 200326230 | — | IN |