MEDICARE: REAL SMILES

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	23066	TX
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
3	1223G0001X	General Practice Dentistry	23066	TX

General Provider Information

NPI Number	:	1649447236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REAL SMILES

Provider Business Mailing Address
First Line	:	3839 MCKINNEY AVE APT 403
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-1417
Country	:	US
Telephone Number	:	818-653-9799
Fax Number	:

Provider Business Practice Location Address
First Line	:	3330 MANSFIELD HWY STE B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119
Country	:	US
Telephone Number	:	818-653-9799
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. RAFFY KOUYOUMDJIAN
Credential	:	D.M.D
Telephone Number	:	818-653-9799

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	05/13/2008

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Directions to “REAL SMILES ” Practice Location

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