Provider Demographics
NPI:1740629039
Name:ELEGANT SMILES DENTISTRY
Entity type:Organization
Organization Name:ELEGANT SMILES DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAKSARFARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-824-5454
Mailing Address - Street 1:4775 KNIGHTS BRIDGE BLVD.
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214
Mailing Address - Country:US
Mailing Address - Phone:614-824-5454
Mailing Address - Fax:
Practice Address - Street 1:4775 KNIGHTS BRIDGE BLVD.
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214
Practice Address - Country:US
Practice Address - Phone:614-824-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21821261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2417772Medicaid