Provider Demographics
NPI:1740913490
Name:SMILES HQ SAN DIEGO
Entity type:Organization
Organization Name:SMILES HQ SAN DIEGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRZAD
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:619-770-8742
Mailing Address - Street 1:6545 BALBOA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3156
Mailing Address - Country:US
Mailing Address - Phone:858-292-7655
Mailing Address - Fax:
Practice Address - Street 1:6545 BALBOA AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3156
Practice Address - Country:US
Practice Address - Phone:858-292-7655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962864884Medicaid