=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366821795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSPER SMILES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2015
-----------------------------------------------------
Last Update Date | 05/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 N COLEMAN ST SUITE 120
-----------------------------------------------------
City | PROSPER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75078-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-347-9617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 N COLEMAN ST SUITE 120
-----------------------------------------------------
City | PROSPER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75078-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER/PRESIDENT
-----------------------------------------------------
Name | VIMAL PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-650-7405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 19056
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 27680
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------