MEDICARE: SMILE CARE NORTHEAST, PLLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1235366519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE CARE NORTHEAST, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 840925
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-0925
Country	:	US
Telephone Number	:	214-757-4500
Fax Number	:	214-757-4501

Provider Business Practice Location Address
First Line	:	808 NE MALL BLVD
Second Line	:
City	:	HURST
State	:	TX
Zip	:	76053-4653
Country	:	US
Telephone Number	:	817-595-9675
Fax Number	:	817-595-9677

Authorized Official
Title or Position	:	OWNER
Name	:	SULMAN AHMED
Credential	:	DMD
Telephone Number	:	972-331-8079

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	05/26/2023

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