# SOUTH BEND SMILES YOUTH DENTISTRY, LLC

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

## Provider details

- **NPI number:** 1902017593
- **Authorized official:** MRS. JENELL STUMP (MANAGER, LICENSING & CREDENTIALING)
- **Authorized official phone:** (615) 750-0343

## Contact information

- **Practice address:** 2332 MIRACLE LN, MISHAWAKA, IN 46545-3012
- **Practice address phone:** (574) 259-5437
- **Practice address fax:** (574) 259-5438
- **Mailing address:** 16 ARCADE UNIT 198747, NASHVILLE, TN 37219-1994
- **Mailing address phone:** (615) 750-0343
- **Mailing address fax:** (615) 986-1705

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 05/24/2007
- **Last updated:** 07/09/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1902017593 | — | MI |
| 05 | — | 200828710A | — | IN |