Provider Demographics
NPI:1285894717
Name:ANGEL SMILE DENTAL CLINIC
Entity type:Organization
Organization Name:ANGEL SMILE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARJANEH
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-772-6435
Mailing Address - Street 1:6909 HILLCROFT ST
Mailing Address - Street 2:STE 1F
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-4822
Mailing Address - Country:US
Mailing Address - Phone:713-772-6435
Mailing Address - Fax:
Practice Address - Street 1:6909 HILLCROFT
Practice Address - Street 2:SUITE 1F
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081
Practice Address - Country:US
Practice Address - Phone:713-772-6435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19925302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161520501Medicaid