Provider Demographics
NPI:1093113680
Name:STATE OF THE ART SMILES, PA
Entity Type:Organization
Organization Name:STATE OF THE ART SMILES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDIEGO MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-985-1800
Mailing Address - Street 1:560A LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-985-1880
Mailing Address - Fax:856-985-7170
Practice Address - Street 1:560A LIPPINCOTT DR
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-985-1880
Practice Address - Fax:856-985-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI01771700122300000X
NJDI02582400122300000X
NJDI025144001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty