Healthcare Provider Details

I. General information

NPI: 1457816431
Provider Name (Legal Business Name): SMILE123PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N VELASCO ST
ANGLETON TX
77515-3197
US

IV. Provider business mailing address

1220 N VELASCO ST
ANGLETON TX
77515-3197
US

V. Phone/Fax

Practice location:
  • Phone: 979-849-5771
  • Fax: 979-849-0555
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TANVI DUSANE
Title or Position: PRESIDENT
Credential:
Phone: 281-853-4249