Provider Demographics
NPI:1063867117
Name:CREATING SMILES FAMILY DENTAL
Entity Type:Organization
Organization Name:CREATING SMILES FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-338-1100
Mailing Address - Street 1:1025 BROAD ST
Mailing Address - Street 2:STE 3
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2844
Mailing Address - Country:US
Mailing Address - Phone:973-338-1100
Mailing Address - Fax:
Practice Address - Street 1:1025 BROAD ST
Practice Address - Street 2:STE 3
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2844
Practice Address - Country:US
Practice Address - Phone:973-338-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053693-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty