Provider Demographics
NPI:1679072417
Name:YOUR GREAT SMILE,INC. A DENTAL HYGIENE PRACTICE OF VANGE LEONIS, RDHAP
Entity type:Organization
Organization Name:YOUR GREAT SMILE,INC. A DENTAL HYGIENE PRACTICE OF VANGE LEONIS, RDHAP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VANGE
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:LEONIS
Authorized Official - Suffix:
Authorized Official - Credentials:RDHAP
Authorized Official - Phone:415-898-7390
Mailing Address - Street 1:926A DIABLO AVE # 122
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4025
Mailing Address - Country:US
Mailing Address - Phone:415-898-7390
Mailing Address - Fax:415-898-7389
Practice Address - Street 1:900 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:RIO VISTA
Practice Address - State:CA
Practice Address - Zip Code:94571-9707
Practice Address - Country:US
Practice Address - Phone:415-898-7390
Practice Address - Fax:415-898-7389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP47261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841355401Medicaid