Provider Demographics
NPI:1518443837
Name:EAST BEACH SMILES LLC
Entity type:Organization
Organization Name:EAST BEACH SMILES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MOSTAFA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOULKHAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-362-0600
Mailing Address - Street 1:4520 PRETTY LAKE AVE
Mailing Address - Street 2:#201
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518
Mailing Address - Country:US
Mailing Address - Phone:757-362-0600
Mailing Address - Fax:757-362-0010
Practice Address - Street 1:4520 PRETTY LAKE AVE
Practice Address - Street 2:#201
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518
Practice Address - Country:US
Practice Address - Phone:757-362-0600
Practice Address - Fax:757-362-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty