Provider Demographics
NPI:1538672787
Name:BRANDON SMILES LLC
Entity Type:Organization
Organization Name:BRANDON SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ATHANASIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOKKAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:205-999-9527
Mailing Address - Street 1:926 WEST LUMSDEN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511
Mailing Address - Country:US
Mailing Address - Phone:813-438-8728
Mailing Address - Fax:813-438-8730
Practice Address - Street 1:926 WEST LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:813-438-8728
Practice Address - Fax:813-438-8730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16761122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty