Provider Demographics
NPI:1093261141
Name:SMILETASTIC DENTAL AND ORTHODONTICS
Entity Type:Organization
Organization Name:SMILETASTIC DENTAL AND ORTHODONTICS
Other - Org Name:BRIGHTERSMILES DENTAL AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MALOUF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-785-3290
Mailing Address - Street 1:2200 AIRPORT FWY
Mailing Address - Street 2:STE 480
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6062
Mailing Address - Country:US
Mailing Address - Phone:817-785-3290
Mailing Address - Fax:682-292-1554
Practice Address - Street 1:2200 AIRPORT FWY
Practice Address - Street 2:STE 480
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6062
Practice Address - Country:US
Practice Address - Phone:817-785-3290
Practice Address - Fax:682-292-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16206122300000X
1223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty