Provider Demographics
NPI:1922499482
Name:FORT WORTH SMILE STUDIO P.L.L.C.
Entity Type:Organization
Organization Name:FORT WORTH SMILE STUDIO P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-263-9014
Mailing Address - Street 1:6115 S HULEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-3403
Mailing Address - Country:US
Mailing Address - Phone:817-236-9014
Mailing Address - Fax:817-263-7081
Practice Address - Street 1:6115 S HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-3403
Practice Address - Country:US
Practice Address - Phone:817-236-9014
Practice Address - Fax:817-263-7081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty