Provider Demographics
NPI:1457724353
Name:BRAZOS VALLEY SMILE RESTORATIONS
Entity Type:Organization
Organization Name:BRAZOS VALLEY SMILE RESTORATIONS
Other - Org Name:SMILE RESTORATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOUETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-846-1121
Mailing Address - Street 1:1615 BARAK LN
Mailing Address - Street 2:STE 5
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3315
Mailing Address - Country:US
Mailing Address - Phone:979-846-1121
Mailing Address - Fax:979-846-5771
Practice Address - Street 1:1615 BARAK LN
Practice Address - Street 2:STE 5
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3315
Practice Address - Country:US
Practice Address - Phone:979-846-1121
Practice Address - Fax:979-846-5771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD226231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty