Basic Information
| Provider Information | |||||||||
| NPI: | 1376891887 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SMILE DESIGN PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 WOLFE NURSERY RD | ||||||||
| Address2: | STE 190 | ||||||||
| City: | STEPHENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764013731 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 WOLFE NURSERY RD | ||||||||
| Address2: | STE 190 | ||||||||
| City: | STEPHENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764013731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172817947 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2012 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | PURI | ||||||||
| AuthorizedOfficialFirstName: | GAURAV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 61772817947 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 24365 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.