Healthcare Provider Details

I. General information

NPI: 1992356919
Provider Name (Legal Business Name): IDEAL SMILES ENTERPRISE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6536 N. UNIVERSITY DRIVE
TAMARAC FL
33321
US

IV. Provider business mailing address

6536 N. UNIVERSITY DR.
TAMARAC FL
33321
US

V. Phone/Fax

Practice location:
  • Phone: 954-933-1705
  • Fax: 954-532-5375
Mailing address:
  • Phone: 954-933-1705
  • Fax: 954-532-5375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIKE HOANG
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 954-933-1705