Provider Demographics
NPI:1265979553
Name:SHINY SMILE DENTAL
Entity type:Organization
Organization Name:SHINY SMILE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MUSTAFA
Authorized Official - Middle Name:GHAZI
Authorized Official - Last Name:ALSAFI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:312-576-3948
Mailing Address - Street 1:1231 CAMBRIAN PARK CT
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5326
Mailing Address - Country:US
Mailing Address - Phone:312-576-3948
Mailing Address - Fax:
Practice Address - Street 1:1231 CAMBRIAN PARK CT
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-5326
Practice Address - Country:US
Practice Address - Phone:312-576-3948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31067302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization