Provider Demographics
NPI:1114412848
Name:GORGEOUS SMILE PLLC
Entity Type:Organization
Organization Name:GORGEOUS SMILE PLLC
Other - Org Name:GORGEOUS SMILE PLLC, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:T
Authorized Official - Last Name:AL-SALIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-278-9239
Mailing Address - Street 1:13113 SHADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-5405
Mailing Address - Country:US
Mailing Address - Phone:619-278-9239
Mailing Address - Fax:
Practice Address - Street 1:4001 9TH ST N STE 218
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1900
Practice Address - Country:US
Practice Address - Phone:619-278-9239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental