Organization
YOUR GREAT SMILE, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VANGE IRENE LEONIS RDHAP,MS (PRESIDENT)
(415) 898-7390
Entity
Organization
Contact information
Practice address
856 CYPRESS AVE, NOVATO, CA 94947-3925
(415) 898-7390
(415) 898-7389
Mailing address
926A DIABLO AVE # 122, NOVATO, CA 94947-4025
(415) 898-7390
(415) 898-7389
Taxonomy
Speciality
Code
Description
License number
State
124Q00000X
Dental Hygienist
Primary
HAP47
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1841355401
—
CA
Enumeration date
06/28/2007
Last updated
08/22/2020
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