=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912404559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE EXPERTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 04/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4810 BEAUREGARD ST STE 200
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22312-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-374-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 YOAKUM PKWY APT 1111
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22304-3731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-877-4989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ANDLEEB REHMAN MAHMOOD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 571-374-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 0401415413
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------