Provider Demographics
NPI:1033618780
Name:GROWING SMILES OF HAVRE DE GRACE
Entity Type:Organization
Organization Name:GROWING SMILES OF HAVRE DE GRACE
Other - Org Name:GROWING SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPOBIANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-996-6691
Mailing Address - Street 1:203 S WASHINGTON ST FL 1
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3244
Mailing Address - Country:US
Mailing Address - Phone:443-996-6691
Mailing Address - Fax:
Practice Address - Street 1:203 S WASHINGTON ST FL 1
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3244
Practice Address - Country:US
Practice Address - Phone:443-996-6691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12180261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental