Provider Demographics
NPI:1316491772
Name:RADIANT SMILE DENTISTRY PLLC
Entity type:Organization
Organization Name:RADIANT SMILE DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PRABHSHARAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDHU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-277-2222
Mailing Address - Street 1:380 E VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1208
Mailing Address - Country:US
Mailing Address - Phone:602-277-2222
Mailing Address - Fax:602-279-3742
Practice Address - Street 1:380 E VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1208
Practice Address - Country:US
Practice Address - Phone:602-277-2222
Practice Address - Fax:602-279-3742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7349122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty