Create-a-Smile, PC

Primary specialty

DentistTaxonomy code 122300000X

License

12010311A Issued in IN

Legal business name

CREATE-A-SMILE, PC

Practice address

2815 N Walnut St
Bloomington, IN 47404-2077

Phone

(812) 332-1405

Fax

(812) 332-4331

NPI assigned

Jan 20, 2010

Last updated

May 17, 2022By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Shannon Kenneth Moore, DMD, MSEDNPI 1194855205

Title

Owner

Phone

(812) 332-1405

Specialties & licenses 3

Addresses

Other identifiers 2

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Shannon Kenneth Moore, DMD MSED

  • Dentist
  • Bloomington, IN
  • NPI 1194855205
  NPD Authorized official
• Devanshi Gajjar, DDS

  • Dentist
  • Westminster, MD
  • NPI 1649895541
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1263945600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1652745600000",
    "number": "1588995229",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2815 N WALNUT ST",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474042077",
            "telephone_number": "812-332-1405",
            "fax_number": "812-332-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2815 N WALNUT ST",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474042077",
            "telephone_number": "812-332-1405",
            "fax_number": "812-332-4331"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CREATE-A-SMILE, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-01-20",
        "last_updated": "2022-05-17",
        "certification_date": "2022-05-17",
        "status": "A",
        "authorized_official_last_name": "MOORE",
        "authorized_official_first_name": "SHANNON",
        "authorized_official_middle_name": "KENNETH",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "812-332-1405",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD, MSED"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IN",
            "license": "12010311A",
            "primary": true
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IN",
            "license": "12011246A",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1194855205",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200326230",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Catherine Crandall
• Stephanie Crane
• Tracy L Crane, OD
• Cameron Crawford, PHARMD
• Joan S Crawford, DO
• Creative Care Solutions, LLC
• Alexandra Elisabeth Creech
• Jayne Crescimbeni-Pierce, C-NP
• Emily Crismore, RBT
• Deleska Crockett, M.A.

• Dentist in Bloomington, IN
• Providers in Bloomington, IN by specialty
• Dentist in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 17, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.