Basic Information
| Provider Information | |||||||||
| NPI: | 1952708430 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMILE MART PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2206 HIGHWAY 16 SOUTH | ||||||||
| Address2: | SUITE 2206 | ||||||||
| City: | GREHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76450 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2206 HIGHWAY 16 SOUTH | ||||||||
| Address2: | SUITE 2206 | ||||||||
| City: | GREHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172817941 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2014 | ||||||||
| LastUpdateDate: | 11/26/2014 | ||||||||
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| AuthorizedOfficialLastName: | PURI | ||||||||
| AuthorizedOfficialFirstName: | GAURAV | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6172817941 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 24365 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.