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General NPI Number Information
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NPI Number | 1316491772
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Entity Type | Organization
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Legal Business Name | RADIANT SMILE DENTISTRY PLLC
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Dates
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Enumeration Date | 08/15/2016
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Last Update Date | 08/15/2016
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Provider Practice Location Address
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Address Line | 380 E VIRGINIA AVE
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City | PHOENIX
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State | AZ
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Zip | 85004-1208
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Country | US
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Telephone | 602-277-2222
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Fax | 602-279-3742
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Provider Business Mailing Address
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Address Line | 380 E VIRGINIA AVE
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City | PHOENIX
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State | AZ
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Zip | 85004-1208
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Country | US
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Telephone | 602-277-2222
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Fax | 602-279-3742
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. PRABHSHARAN SANDHU
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Credential | D.D.S.
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Telephone | 602-277-2222
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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 | 7349
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License Number State | AZ
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