Provider Demographics
NPI:1578876520
Name:PURE SMILES ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:PURE SMILES ORTHODONTICS PLLC
Other - Org Name:PURE SMILES ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SILVANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ MANZUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:512-522-5446
Mailing Address - Street 1:4301 W WILLIAM CANNON DR
Mailing Address - Street 2:BUILDING E, SUITE 300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1473
Mailing Address - Country:US
Mailing Address - Phone:512-522-5446
Mailing Address - Fax:
Practice Address - Street 1:4301 W WILLIAM CANNON DR
Practice Address - Street 2:BUILDING E, SUITE 300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1473
Practice Address - Country:US
Practice Address - Phone:512-522-5446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23810261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental