Provider Demographics
NPI:1235540253
Name:GREAT EXPRESSION SMILES
Entity Type:Organization
Organization Name:GREAT EXPRESSION SMILES
Other - Org Name:GREAT EXPRESSION SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-496-2343
Mailing Address - Street 1:2501 W INTERSTATE 20 STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3948
Mailing Address - Country:US
Mailing Address - Phone:817-496-2343
Mailing Address - Fax:817-665-3822
Practice Address - Street 1:6426 MEADOWBROOK DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-5123
Practice Address - Country:US
Practice Address - Phone:817-496-2343
Practice Address - Fax:817-665-3822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202009121Medicaid