MEDICARE: PROFESSIONAL SMILE STUDIO

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1336809870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL SMILE STUDIO

Provider Business Mailing Address
First Line	:	1732 PROFESSIONAL DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-2105
Country	:	US
Telephone Number	:	916-333-5903
Fax Number	:

Provider Business Practice Location Address
First Line	:	1732 PROFESSIONAL DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-2105
Country	:	US
Telephone Number	:	916-333-5903
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. KHATEREH N/A TOLOOEI
Credential	:	DDS
Telephone Number	:	916-897-6469

Provider Enumeration Date	:	12/24/2021
Last Update Date	:	12/24/2021

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Directions to “PROFESSIONAL SMILE STUDIO ” Practice Location

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