Provider Demographics
NPI:1174278311
Name:MIRACLE SMILE FAMILY DENTAL AND ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:MIRACLE SMILE FAMILY DENTAL AND ORTHODONTICS PLLC
Other - Org Name:MIRACLE SMILE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:NISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-346-6612
Mailing Address - Street 1:8628 FOREST GLEN DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4201
Mailing Address - Country:US
Mailing Address - Phone:469-346-6612
Mailing Address - Fax:
Practice Address - Street 1:1001 S HIGHWAY 377
Practice Address - Street 2:107
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227
Practice Address - Country:US
Practice Address - Phone:469-346-6112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty