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General NPI Number Information
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NPI Number | 1093261141
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Entity Type | Organization
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Legal Business Name | SMILETASTIC DENTAL AND ORTHODONTICS
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Dates
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Enumeration Date | 08/29/2016
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Last Update Date | 08/29/2016
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Provider Practice Location Address
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Address Line | 2200 AIRPORT FWY STE 480
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City | BEDFORD
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State | TX
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Zip | 76022-6062
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Country | US
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Telephone | 817-785-3290
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Fax | 682-292-1554
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Provider Business Mailing Address
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Address Line | 2200 AIRPORT FWY STE 480
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City | BEDFORD
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State | TX
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Zip | 76022-6062
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Country | US
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Telephone | 817-785-3290
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Fax | 682-292-1554
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD JOHN MALOUF
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Credential | DDS
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Telephone | 817-785-3290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 16206
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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