Organization
BRAZOS VALLEY SMILES, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KETAN ARUN SUKKAWALA DDS (PRESIDENT)
(979) 694-5200
Entity
Organization
Contact information
Practice address
1103 ROCK PRAIRIE RD STE 1001, COLLEGE STATION, TX 77845-8344
(979) 694-5200
(979) 694-5223
Mailing address
1103 ROCK PRAIRIE RD STE 1001, COLLEGE STATION, TX 77845-8344
(979) 694-5200
(979) 694-5223
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
19635
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009547301
—
TX
05
—
090878203
—
TX
01
—
12102
DENTAL LICENSE NUMBER
TX
01
—
19635
DENTAL LICENSE NUMBER
TX
01
—
26291
DENTAL LICENSE NUMBER
TX
01
—
26496
DENTAL LICENSE NUMBER
TX
05
—
280969101
—
TX
05
—
316310702
—
TX
Enumeration date
08/18/2011
Last updated
06/11/2019
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