=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518661578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUMINOUS SMILE, CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2023
-----------------------------------------------------
Last Update Date | 03/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 BALTIMORE ANNAPOLIS BLVD
-----------------------------------------------------
City | SEVERNA PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21146-3930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-549-2015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 WATERSIDE DR UNIT 212
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21701-3257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-549-2015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST/ OWNER
-----------------------------------------------------
Name | DR. SAHAR ZARE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 240-549-2015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------