=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649447236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REAL SMILES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2008
-----------------------------------------------------
Last Update Date | 05/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3330 MANSFIELD HWY STE B
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-653-9799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3839 MCKINNEY AVE APT 403
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-1417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-653-9799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. RAFFY KOUYOUMDJIAN
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 818-653-9799
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 23066
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 23066
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------