=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922847078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAPPY SMILES ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2024
-----------------------------------------------------
Last Update Date | 05/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 ASHOURIAN AVE STE 211
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32092-5107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-201-4844
-----------------------------------------------------
Fax | 904-201-4432
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 ASHOURIAN AVE STE 211
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32092-5107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-201-4844
-----------------------------------------------------
Fax | 904-201-4432
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK KOMFORTI
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 904-201-4844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------