Provider Demographics
NPI:1689794505
Name:CORAL RIDGE SMILE
Entity Type:Organization
Organization Name:CORAL RIDGE SMILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANDANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIR ESMAILI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-990-6543
Mailing Address - Street 1:2324 NE 53RD ST.
Mailing Address - Street 2:
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308
Mailing Address - Country:US
Mailing Address - Phone:954-990-6543
Mailing Address - Fax:954-941-4876
Practice Address - Street 1:2324 NE 53RD ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3212
Practice Address - Country:US
Practice Address - Phone:954-990-6543
Practice Address - Fax:954-491-4876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANDANA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-02
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty