Basic Information
| Provider Information | |||||||||
| NPI: | 1114058914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALL SMILES DENTAL PROFESSIONALS, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALL SMILES DENTAL CENTER, PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 LBJ FREEWAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752446158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143425757 | ||||||||
| FaxNumber: | 2143404868 | ||||||||
| Practice Location | |||||||||
| Address1: | 2628 MATLOCK RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760152525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174683077 | ||||||||
| FaxNumber: | 8174602876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CODEL | ||||||||
| AuthorizedOfficialFirstName: | ADRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2146425757 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 16206 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223X0400X | 16206 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223S0112X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 147940412 | 05 | TX | MEDICAID | 1479404-13 | 05 | TX | MEDICAID | 147940401 | 05 | TX | MEDICAID | 147940403 | 05 | TX | MEDICAID | 147940407 | 05 | TX | MEDICAID | 147940405 | 05 | TX | MEDICAID | 147940406 | 05 | TX | MEDICAID | 147940408 | 05 | TX | MEDICAID | 147940409 | 05 | TX | MEDICAID | 147940404 | 05 | TX | MEDICAID | 147940410 | 05 | TX | MEDICAID | 147940411 | 05 | TX | MEDICAID |