Provider Demographics
NPI:1033965009
Name:SMILE BAR PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:SMILE BAR PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTIUK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:941-875-7002
Mailing Address - Street 1:7329 CORDOBA DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724-6251
Mailing Address - Country:US
Mailing Address - Phone:941-875-7002
Mailing Address - Fax:
Practice Address - Street 1:9901 BRODIE LN STE 130
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5889
Practice Address - Country:US
Practice Address - Phone:737-204-7208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental