Provider Demographics
NPI:1457757213
Name:SMILESRUSAT SECURITY BLVD
Entity Type:Organization
Organization Name:SMILESRUSAT SECURITY BLVD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RADPARVAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-621-2971
Mailing Address - Street 1:6666 SECURITY BLVD
Mailing Address - Street 2:SUIT 11
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4013
Mailing Address - Country:US
Mailing Address - Phone:410-944-6666
Mailing Address - Fax:
Practice Address - Street 1:6666 SECURITY BLVD
Practice Address - Street 2:SUIT 11
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-4013
Practice Address - Country:US
Practice Address - Phone:410-944-6666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD141161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty