Provider Demographics
NPI:1417497330
Name:I SMILE DENTAL GROUP
Entity Type:Organization
Organization Name:I SMILE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TU
Authorized Official - Middle Name:QUYNH
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:1714-602-6327
Mailing Address - Street 1:2710 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8750
Mailing Address - Country:US
Mailing Address - Phone:171-460-2632
Mailing Address - Fax:714-602-6275
Practice Address - Street 1:2710 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8750
Practice Address - Country:US
Practice Address - Phone:171-460-2632
Practice Address - Fax:714-602-6275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49617Medicaid