Basic Information
| Provider Information | |||||||||
| NPI: | 1295202125 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SMILE COUNTRY DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3075 BEACON BLVD | ||||||||
| Address2: | |||||||||
| City: | W SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956913462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167021213 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 140 STONY POINT RD STE A | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954014121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075783188 | ||||||||
| FaxNumber: | 9163843844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2018 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | KALIKA | ||||||||
| AuthorizedOfficialFirstName: | YAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9167021213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.