=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437686482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILENDODONTICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2017
-----------------------------------------------------
Last Update Date | 05/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9520 TALBERT AVE
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-5145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-587-9041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9520 TALBERT AVE
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-5145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENDODONTIST
-----------------------------------------------------
Name | MICHELLE DANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-552-8207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 60157
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------