Provider Demographics
NPI:1033531124
Name:SMILES OF WATERBURY, LLC
Entity Type:Organization
Organization Name:SMILES OF WATERBURY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS/FINANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTA MARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-997-0569
Mailing Address - Street 1:1127 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2764
Mailing Address - Country:US
Mailing Address - Phone:203-527-4614
Mailing Address - Fax:203-527-4814
Practice Address - Street 1:1127 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2764
Practice Address - Country:US
Practice Address - Phone:203-527-4614
Practice Address - Fax:203-527-4814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty