MEDICARE: THE SMILE LOUNGE 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1790309094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SMILE LOUNGE PLLC

Provider Business Mailing Address
First Line	:	PO BOX 625
Second Line	:
City	:	RED OAK
State	:	TX
Zip	:	75154-0625
Country	:	US
Telephone Number	:	602-753-6706
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 W CAMP WISDOM RD # 140
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-4642
Country	:	US
Telephone Number	:	602-753-6706
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	SHAILENDRA DANIELS
Credential	:	DMD
Telephone Number	:	602-753-6706

Provider Enumeration Date	:	06/02/2020
Last Update Date	:	06/02/2020

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Directions to “THE SMILE LOUNGE PLLC ” Practice Location

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