Provider Demographics
NPI:1538358643
Name:NORTH PARK SMILES
Entity type:Organization
Organization Name:NORTH PARK SMILES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-220-0549
Mailing Address - Street 1:3795 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3631
Mailing Address - Country:US
Mailing Address - Phone:619-220-0548
Mailing Address - Fax:619-220-8604
Practice Address - Street 1:3795 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-3631
Practice Address - Country:US
Practice Address - Phone:619-220-0548
Practice Address - Fax:619-220-8604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA443061223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty