Healthcare Provider Details

I. General information

NPI: 1922847078
Provider Name (Legal Business Name): HAPPY SMILES ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 ASHOURIAN AVE STE 211
ST AUGUSTINE FL
32092-5107
US

IV. Provider business mailing address

206 ASHOURIAN AVE STE 211
ST AUGUSTINE FL
32092-5107
US

V. Phone/Fax

Practice location:
  • Phone: 904-201-4844
  • Fax: 904-201-4432
Mailing address:
  • Phone: 904-201-4844
  • Fax: 904-201-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK KOMFORTI
Title or Position: OWNER
Credential: DMD
Phone: 904-201-4844