Provider Demographics
NPI:1891942231
Name:SMILE MAGICDENTAL PA
Entity Type:Organization
Organization Name:SMILE MAGICDENTAL PA
Other - Org Name:SMILE MAGIC DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:POONAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOKHALE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:214-544-7645
Mailing Address - Street 1:5261 MCKINNEY RANCH PKWY
Mailing Address - Street 2:STE # 400
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-6831
Mailing Address - Country:US
Mailing Address - Phone:214-544-7645
Mailing Address - Fax:
Practice Address - Street 1:5261 MCKINNEY RANCH PKWY
Practice Address - Street 2:STE # 400
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-6831
Practice Address - Country:US
Practice Address - Phone:214-544-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20676305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1487816252OtherNPI TYPE 1