Healthcare Provider Details

I. General information

NPI: 1366821795
Provider Name (Legal Business Name): PROSPER SMILES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N COLEMAN ST SUITE 120
PROSPER TX
75078-2303
US

IV. Provider business mailing address

821 N COLEMAN ST SUITE 120
PROSPER TX
75078-2303
US

V. Phone/Fax

Practice location:
  • Phone: 972-347-9617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27680
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19056
License Number StateTX

VIII. Authorized Official

Name: VIMAL PATEL
Title or Position: MANAGING MEMBER/PRESIDENT
Credential:
Phone: 402-650-7405