Provider Demographics
NPI:1386924694
Name:BRAZOS VALLEY SMILES, PC
Entity type:Organization
Organization Name:BRAZOS VALLEY SMILES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:ARUN
Authorized Official - Last Name:SUKKAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-694-5200
Mailing Address - Street 1:1103 ROCK PRAIRIE RD STE 1001
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8344
Mailing Address - Country:US
Mailing Address - Phone:979-694-5200
Mailing Address - Fax:979-694-5223
Practice Address - Street 1:1103 ROCK PRAIRIE RD STE 1001
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8344
Practice Address - Country:US
Practice Address - Phone:979-694-5200
Practice Address - Fax:979-694-5223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19635261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280969101Medicaid
TX009547301Medicaid
TX26291OtherDENTAL LICENSE NUMBER
TX090878203Medicaid
TX12102OtherDENTAL LICENSE NUMBER
TX19635OtherDENTAL LICENSE NUMBER
TX316310702Medicaid
TX26496OtherDENTAL LICENSE NUMBER