Provider Demographics
NPI:1831660026
Name:HAPPY SMILES OF PORT SAINT LUCIE
Entity Type:Organization
Organization Name:HAPPY SMILES OF PORT SAINT LUCIE
Other - Org Name:HAPPY SMILES OF FORT MYERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZADOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-305-2958
Mailing Address - Street 1:1905 CLINT MOORE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2660
Mailing Address - Country:US
Mailing Address - Phone:561-241-7656
Mailing Address - Fax:
Practice Address - Street 1:2675 WINKLER AVE STE 450
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9329
Practice Address - Country:US
Practice Address - Phone:561-241-7656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAPPY SMILES OF PORT SAINT LUCIE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-16
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty