Provider Demographics
NPI:1427897701
Name:COUNTRY CLUB DENTAL, INC. / DBA: SUNNY SMILE DENTAL, INC.
Entity type:Organization
Organization Name:COUNTRY CLUB DENTAL, INC. / DBA: SUNNY SMILE DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANEAL
Authorized Official - Middle Name:NARENDRA
Authorized Official - Last Name:MISTRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-850-6700
Mailing Address - Street 1:9 CHARING CROSS CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-0408
Mailing Address - Country:US
Mailing Address - Phone:505-850-6700
Mailing Address - Fax:
Practice Address - Street 1:317 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5892
Practice Address - Country:US
Practice Address - Phone:505-850-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty