Provider Demographics
NPI:1902007826
Name:DIVERSIFIED MOBILE SMILES
Entity Type:Organization
Organization Name:DIVERSIFIED MOBILE SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RDHAP44
Authorized Official - Phone:510-227-5804
Mailing Address - Street 1:1271 WASHINGTON AVE
Mailing Address - Street 2:810
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3646
Mailing Address - Country:US
Mailing Address - Phone:510-227-5804
Mailing Address - Fax:510-227-5804
Practice Address - Street 1:3016 SAN JOSE AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4834
Practice Address - Country:US
Practice Address - Phone:510-227-5804
Practice Address - Fax:510-227-5804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP44124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty