1871251058 NPI number — SMILE ARK PEDIATRIC DENTISTRY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871251058 NPI number — SMILE ARK PEDIATRIC DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILE ARK PEDIATRIC 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:
Provider Other Organization Name Type Code:
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:
1871251058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
354 WHEELERS FARMS RD UNIT 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06461-1803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-372-2532
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2480 BLACK ROCK TPKE # S1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06825-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-763-4200
Provider Business Practice Location Address Fax Number:
203-763-4232
Provider Enumeration Date:
12/04/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
EUNICE
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
617-372-2532

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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