Provider Demographics
NPI:1053665414
Name:SMILEALIGN ORTHODONTICS
Entity Type:Organization
Organization Name:SMILEALIGN ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:SAMI
Authorized Official - Last Name:WOHL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-336-7190
Mailing Address - Street 1:1680 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1312
Mailing Address - Country:US
Mailing Address - Phone:718-336-7190
Mailing Address - Fax:718-645-2024
Practice Address - Street 1:1680 E 19TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1312
Practice Address - Country:US
Practice Address - Phone:718-336-7190
Practice Address - Fax:718-645-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046387-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1306926464Medicaid