Provider Demographics
NPI:1093155020
Name:FRESH SMILE, PC
Entity Type:Organization
Organization Name:FRESH SMILE, PC
Other - Org Name:LUMEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:FARNAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:DIANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-517-5375
Mailing Address - Street 1:3222 HILLCROFT ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-5806
Mailing Address - Country:US
Mailing Address - Phone:281-999-9999
Mailing Address - Fax:
Practice Address - Street 1:3222 HILLCROFT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-5806
Practice Address - Country:US
Practice Address - Phone:281-999-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty