Provider Demographics
NPI:1194991646
Name:BEAUTIFUL SMILES DENTAL LLC
Entity type:Organization
Organization Name:BEAUTIFUL SMILES DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TATE
Authorized Official - Middle Name:
Authorized Official - Last Name:TODOROVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-487-1551
Mailing Address - Street 1:18521 101ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3803
Mailing Address - Country:US
Mailing Address - Phone:425-487-1551
Mailing Address - Fax:425-487-2160
Practice Address - Street 1:18521 101ST AVE NE
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3803
Practice Address - Country:US
Practice Address - Phone:425-487-1551
Practice Address - Fax:425-487-2160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000107211223G0001X
WADE000107051223G0001X
WADE000098911223P0700X
WADN00000331122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No122400000XDental ProvidersDenturistGroup - Single Specialty