Provider Demographics
NPI:1740886860
Name:GRACEFUL SMILES LLC
Entity type:Organization
Organization Name:GRACEFUL SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-677-7202
Mailing Address - Street 1:6120 BRANDON AVE STE 317
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2504
Mailing Address - Country:US
Mailing Address - Phone:703-451-3303
Mailing Address - Fax:
Practice Address - Street 1:6120 BRANDON AVE STE 317
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2504
Practice Address - Country:US
Practice Address - Phone:703-451-3303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty