Provider Demographics
NPI:1073987301
Name:DYNAMIC SMILE DENTAL PLLC
Entity Type:Organization
Organization Name:DYNAMIC SMILE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-219-8230
Mailing Address - Street 1:80 BOWERY
Mailing Address - Street 2:ROOM #400
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4614
Mailing Address - Country:US
Mailing Address - Phone:212-219-8230
Mailing Address - Fax:
Practice Address - Street 1:80 BOWERY
Practice Address - Street 2:ROOM #400
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4614
Practice Address - Country:US
Practice Address - Phone:212-219-8230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty