Provider Demographics
NPI:1730569997
Name:CLEAN SMILE DENTAL INC
Entity type:Organization
Organization Name:CLEAN SMILE DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAWAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAME
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:313-704-2886
Mailing Address - Street 1:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-0144
Mailing Address - Country:US
Mailing Address - Phone:313-704-2886
Mailing Address - Fax:
Practice Address - Street 1:2213 N ROSEVERE AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1244
Practice Address - Country:US
Practice Address - Phone:313-704-2886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902010443124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty