Provider Demographics
NPI:1952778862
Name:HEALTHY SMILES 4 KIDS, PC
Entity Type:Organization
Organization Name:HEALTHY SMILES 4 KIDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RALSTON
Authorized Official - Last Name:GOBER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-428-8575
Mailing Address - Street 1:5708 COLLEYVILLE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6064
Mailing Address - Country:US
Mailing Address - Phone:817-428-8575
Mailing Address - Fax:817-577-3970
Practice Address - Street 1:5708 COLLEYVILLE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6064
Practice Address - Country:US
Practice Address - Phone:817-428-8575
Practice Address - Fax:817-577-3970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16709122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091175203Medicaid
TX091175202Medicaid