Provider Demographics
NPI:1831554708
Name:ORTHODONTIC SMILE DESIGN, PC
Entity type:Organization
Organization Name:ORTHODONTIC SMILE DESIGN, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FERNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:972-263-1755
Mailing Address - Street 1:325 W WESTCHESTER PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2857
Mailing Address - Country:US
Mailing Address - Phone:972-263-1755
Mailing Address - Fax:972-264-6226
Practice Address - Street 1:325 W WESTCHESTER PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2857
Practice Address - Country:US
Practice Address - Phone:972-263-1755
Practice Address - Fax:972-264-6226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1223S0112X
TX216071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty