1487943635 NPI number — WORCESTER SMILES YOUTH DENTISTRY, LLC

Table of content: (NPI 1487943635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487943635 NPI number — WORCESTER SMILES YOUTH DENTISTRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WORCESTER SMILES YOUTH DENTISTRY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STRAIGHT SMILES OF WORCESTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487943635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 ARCADE UNIT 198747
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37219-1994
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-750-0343
Provider Business Mailing Address Fax Number:
615-986-1705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
388 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01610-1025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-798-6565
Provider Business Practice Location Address Fax Number:
508-798-6687
Provider Enumeration Date:
03/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
STUMP
Authorized Official First Name:
JENELL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, L & C
Authorized Official Telephone Number:
615-750-0343

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110088462A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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