Provider Demographics
NPI:1558552364
Name:SUPER SMILES DENTAL
Entity Type:Organization
Organization Name:SUPER SMILES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-675-8753
Mailing Address - Street 1:2110 N GALLOWAY AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-5738
Mailing Address - Country:US
Mailing Address - Phone:972-216-0300
Mailing Address - Fax:972-216-0700
Practice Address - Street 1:2110 N GALLOWAY AVE STE 120
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-5738
Practice Address - Country:US
Practice Address - Phone:972-216-0300
Practice Address - Fax:972-216-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty