Basic Information
| Provider Information | |||||||||
| NPI: | 1578894077 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULTON ROAD SMILES, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALL SMILES DENTAL & ORTHODONTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 LBJ FREEWAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752446158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143425757 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2982 FULTON ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770095738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143425757 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2010 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | CODEL | ||||||||
| AuthorizedOfficialFirstName: | ADRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2143425757 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.