Provider Demographics
NPI:1356518310
Name:A BEAUTIFUL SMILE MEANS A BETTER LIFE 3
Entity type:Organization
Organization Name:A BEAUTIFUL SMILE MEANS A BETTER LIFE 3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-430-2740
Mailing Address - Street 1:5512 BRITTON DR STE 208
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815
Mailing Address - Country:US
Mailing Address - Phone:562-430-2740
Mailing Address - Fax:562-430-0466
Practice Address - Street 1:5512 BRITTON DR STE 208
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815
Practice Address - Country:US
Practice Address - Phone:562-430-2740
Practice Address - Fax:562-430-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA506871223G0001X
CA200921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty