Provider Demographics
NPI:1548773773
Name:DALLAS DENTAL SMILES
Entity Type:Organization
Organization Name:DALLAS DENTAL SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-674-7176
Mailing Address - Street 1:455 NATHAN DEAN BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4921
Mailing Address - Country:US
Mailing Address - Phone:678-674-7176
Mailing Address - Fax:
Practice Address - Street 1:455 NATHAN DEAN BLVD STE 109
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4921
Practice Address - Country:US
Practice Address - Phone:678-674-7176
Practice Address - Fax:
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
GADNO135541223G0001X
GADNO152611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty