MEDICARE: FRESH SMILE, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		TX

General Provider Information

NPI Number	:	1093155020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH SMILE, PC

Provider Business Mailing Address
First Line	:	3222 HILLCROFT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77057-5806
Country	:	US
Telephone Number	:	281-999-9999
Fax Number	:

Provider Business Practice Location Address
First Line	:	3222 HILLCROFT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77057-5806
Country	:	US
Telephone Number	:	281-999-9999
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	MRS. FARNAZ DIANI
Credential	:	D.D.S.
Telephone Number	:	713-517-5375

Provider Enumeration Date	:	07/05/2013
Last Update Date	:	07/05/2013

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