Provider Demographics
NPI:1669645461
Name:AMAZING SMILES DENTAL, LLC
Entity type:Organization
Organization Name:AMAZING SMILES DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:HAIDER ALI
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:513-367-9464
Mailing Address - Street 1:1140 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-1524
Mailing Address - Country:US
Mailing Address - Phone:513-367-9464
Mailing Address - Fax:513-367-9465
Practice Address - Street 1:1140 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-1524
Practice Address - Country:US
Practice Address - Phone:513-367-9464
Practice Address - Fax:513-367-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-12
Last Update Date:2008-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH21642122300000X
OHOH215361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2492726Medicaid