Provider Demographics
NPI:1619492519
Name:LIFE SMILE DENTAL PLLC
Entity Type:Organization
Organization Name:LIFE SMILE DENTAL PLLC
Other - Org Name:LIFE SMILE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRAVAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ABBARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:832-895-3405
Mailing Address - Street 1:211 W EL DORADO BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-6533
Mailing Address - Country:US
Mailing Address - Phone:832-895-3405
Mailing Address - Fax:281-408-4031
Practice Address - Street 1:211 W EL DORADO BLVD STE C
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-6533
Practice Address - Country:US
Practice Address - Phone:832-895-3405
Practice Address - Fax:281-408-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27239261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1235417767OtherNPI
TX27239OtherTEXAS LICENSE