Provider Demographics
NPI:1457878415
Name:SMILE COMMUNITY CLINIC INC
Entity Type:Organization
Organization Name:SMILE COMMUNITY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAMAVAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-471-9292
Mailing Address - Street 1:670 W. SAN MARCOS BLVD STE 103-B
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078
Mailing Address - Country:US
Mailing Address - Phone:760-471-9292
Mailing Address - Fax:760-471-9293
Practice Address - Street 1:670 W. SAN MARCOS BLVD. STE 103-B
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078
Practice Address - Country:US
Practice Address - Phone:760-471-9292
Practice Address - Fax:760-471-9293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty