Provider Demographics
NPI:1093910143
Name:SMILE DENTAL OFFICE, P.C.
Entity Type:Organization
Organization Name:SMILE DENTAL OFFICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-372-5640
Mailing Address - Street 1:1152 CLINTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111
Mailing Address - Country:US
Mailing Address - Phone:973-372-5640
Mailing Address - Fax:973-371-7697
Practice Address - Street 1:1152 CLINTON AVENUE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111
Practice Address - Country:US
Practice Address - Phone:973-372-5640
Practice Address - Fax:973-371-7697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ19126122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9025600Medicaid