Healthcare Provider Details

I. General information

NPI: 1194219139
Provider Name (Legal Business Name): SMILE STUDIO SPECIALIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7787 LEESBURG PIKE # 200
FALLS CHURCH VA
22043-2412
US

IV. Provider business mailing address

7787 LEESBURG PIKE # 200
FALLS CHURCH VA
22043-2412
US

V. Phone/Fax

Practice location:
  • Phone: 703-982-2222
  • Fax: 703-982-2223
Mailing address:
  • Phone: 703-982-2222
  • Fax: 703-982-2223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401415327
License Number StateVA

VIII. Authorized Official

Name: ELI JANABI
Title or Position: OWNER
Credential:
Phone: 919-665-5555