Provider Demographics
NPI:1093384257
Name:START SMILING DENTAL IMPLANT CENTERS LLC
Entity Type:Organization
Organization Name:START SMILING DENTAL IMPLANT CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:PETRUNGARO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-386-6351
Mailing Address - Street 1:330 W FRONTAGE RD FL 2B
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3467
Mailing Address - Country:US
Mailing Address - Phone:847-386-6351
Mailing Address - Fax:
Practice Address - Street 1:330 W FRONTAGE RD FL 2B
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3467
Practice Address - Country:US
Practice Address - Phone:847-386-6351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental