Provider Demographics
NPI:1730959834
Name:LUCKY SMILES LLC
Entity type:Organization
Organization Name:LUCKY SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAMATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALISHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-207-9775
Mailing Address - Street 1:755 HIGHWAY 121 BYP STE A200
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-8189
Mailing Address - Country:US
Mailing Address - Phone:972-315-9214
Mailing Address - Fax:
Practice Address - Street 1:755 HIGHWAY 121 BYP STE A200
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8189
Practice Address - Country:US
Practice Address - Phone:972-315-9214
Practice Address - Fax:972-315-9216
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUCKY SMILE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty