Provider Demographics
NPI:1730938861
Name:MYSTIC SMILES CHILDREN AND ADULT DENTISTRY
Entity type:Organization
Organization Name:MYSTIC SMILES CHILDREN AND ADULT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:AZIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:PRADHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:281-202-7938
Mailing Address - Street 1:1721 LADY BETTYE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 PARKER RD STE 110
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4864
Practice Address - Country:US
Practice Address - Phone:469-557-5127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty