Provider Demographics
NPI:1417264524
Name:ELEGANT SMILES
Entity Type:Organization
Organization Name:ELEGANT SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SASAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODABAKHSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-735-8900
Mailing Address - Street 1:17610 MIDWAY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6741
Mailing Address - Country:US
Mailing Address - Phone:972-735-8900
Mailing Address - Fax:
Practice Address - Street 1:17610 MIDWAY RD STE 110
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-6741
Practice Address - Country:US
Practice Address - Phone:972-735-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1732828-09Medicaid