Provider Demographics
NPI:1649447236
Name:REAL SMILES
Entity type:Organization
Organization Name:REAL SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUYOUMDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-653-9799
Mailing Address - Street 1:3839 MCKINNEY AVE APT 403
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-1417
Mailing Address - Country:US
Mailing Address - Phone:818-653-9799
Mailing Address - Fax:
Practice Address - Street 1:3330 MANSFIELD HWY STE B
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119
Practice Address - Country:US
Practice Address - Phone:818-653-9799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23066122300000X, 1223G0001X
1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty