Provider Demographics
NPI:1811196249
Name:SMILE DENTAL
Entity Type:Organization
Organization Name:SMILE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAD
Authorized Official - Middle Name:
Authorized Official - Last Name:RADULOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-204-6661
Mailing Address - Street 1:10920 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3809
Mailing Address - Country:US
Mailing Address - Phone:310-204-6661
Mailing Address - Fax:310-204-6662
Practice Address - Street 1:10920 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3809
Practice Address - Country:US
Practice Address - Phone:310-204-6661
Practice Address - Fax:310-204-6662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB44531-01Medicaid
CA1679643001OtherNPI TYPE 1