Provider Demographics
NPI:1275802894
Name:SMILE EXPRESS INC.
Entity Type:Organization
Organization Name:SMILE EXPRESS INC.
Other - Org Name:PARKRIDGE DENTAL SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRINCIPAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORACEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-735-0200
Mailing Address - Street 1:520 E PARKRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 E PARKRIDGE AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1040
Practice Address - Country:US
Practice Address - Phone:951-735-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA455361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45536OtherDENTAL LICENSE