Brazos Valley Smiles, PC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

License

19635 Issued in TX

Legal business name

BRAZOS VALLEY SMILES, PC

Practice address

1103 Rock Prairie Rd Ste 1001
College Station, TX 77845-8344

Phone

(979) 694-5200

Fax

(979) 694-5223

NPI assigned

Aug 18, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Ketan Arun Sukkawala, DDSNPI 1710030077

Title

President

Phone

(979) 694-5200

Specialties & licenses 1

Addresses

Other identifiers 8

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Ketan Arun Sukkawala, DDS

  • Pediatric Dentistry
  • College Station, TX
  • NPI 1710030077
  NPD (past) Authorized official
• Brian James Barras, D.D.S.

  • Pediatric Dentistry
  • College Station, TX
  • NPI 1649566431
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1313625600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560211200000",
    "number": "1386924694",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1103 ROCK PRAIRIE RD STE 1001",
            "city": "COLLEGE STATION",
            "state": "TX",
            "postal_code": "778458344",
            "telephone_number": "979-694-5200",
            "fax_number": "979-694-5223"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1103 ROCK PRAIRIE RD STE 1001",
            "city": "COLLEGE STATION",
            "state": "TX",
            "postal_code": "778458344",
            "telephone_number": "979-694-5200",
            "fax_number": "979-694-5223"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1109 Rock Prairie Rd",
            "address_2": "Ste. 300",
            "address_purpose": "LOCATION",
            "city": "College Station",
            "state": "TX",
            "postal_code": "778458651",
            "country_code": "US",
            "telephone_number": "979-694-5200",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BRAZOS VALLEY SMILES, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-08-18",
        "last_updated": "2019-06-11",
        "status": "A",
        "authorized_official_last_name": "SUKKAWALA",
        "authorized_official_first_name": "KETAN",
        "authorized_official_middle_name": "ARUN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "979-694-5200",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "TX",
            "license": "19635",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "280969101",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "009547301",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL LICENSE NUMBER",
            "identifier": "26291",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "090878203",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL LICENSE NUMBER",
            "identifier": "12102",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL LICENSE NUMBER",
            "identifier": "19635",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "316310702",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL LICENSE NUMBER",
            "identifier": "26496",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brazos Valley Pathology, PLLC
• Brazos Valley Plastic Surgery Center
• Brazos Valley Plastic Surgery Center LLC
• Brazos Valley Psychiatry
• Brazos Valley Sleep Diagnostics
• Brazos Valley Speech Therapy, PLLC
• Brazos Valley Womens Center PA
• Brazos Weight and Wellness Medicine PLLC
• Brazos Wound Associates, PA
• Brian S Black DDS PLLC

• Dental Clinic/Center in College Station, TX
• Providers in College Station, TX by specialty
• Dental Clinic/Center in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.