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General NPI Number Information
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NPI Number | 1417264524
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Entity Type | Organization
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Legal Business Name | ELEGANT SMILES
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Dates
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Enumeration Date | 09/10/2010
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Last Update Date | 09/10/2010
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Provider Practice Location Address
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Address Line | 17610 MIDWAY RD STE 110
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City | DALLAS
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State | TX
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Zip | 75287-6741
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Country | US
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Telephone | 972-735-8900
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Fax |
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Provider Business Mailing Address
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Address Line | 17610 MIDWAY RD STE 110
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City | DALLAS
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State | TX
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Zip | 75287-6741
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Country | US
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Telephone | 972-735-8900
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER/PRESIDENT
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Name | MR. SASAN KHODABAKHSH
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Credential | D.D.S
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Telephone | 972-735-8900
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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 | 22300
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License Number State | TX
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