Provider Demographics
NPI:1497123996
Name:PHOENIX DENTAL PROVIDERS, INC.
Entity Type:Organization
Organization Name:PHOENIX DENTAL PROVIDERS, INC.
Other - Org Name:SMILE CLINIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:YOUSSEF
Authorized Official - Middle Name:
Authorized Official - Last Name:SALLOUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-730-7012
Mailing Address - Street 1:6520 N 7TH AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1173
Mailing Address - Country:US
Mailing Address - Phone:602-730-7012
Mailing Address - Fax:
Practice Address - Street 1:6520 N 7TH AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1173
Practice Address - Country:US
Practice Address - Phone:602-730-7012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD05888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty