Provider Demographics
NPI:1104833862
Name:HEALTHY SMILES DENTAL CARE, P.C.
Entity Type:Organization
Organization Name:HEALTHY SMILES DENTAL CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-623-2601
Mailing Address - Street 1:2O MAIN ST
Mailing Address - Street 2:STE 17
Mailing Address - City:WINDSOR LOCKS
Mailing Address - State:CT
Mailing Address - Zip Code:06096-1916
Mailing Address - Country:US
Mailing Address - Phone:860-623-2601
Mailing Address - Fax:860-370-5467
Practice Address - Street 1:20 MAIN ST STE 17
Practice Address - Street 2:
Practice Address - City:WINDSOR LOCKS
Practice Address - State:CT
Practice Address - Zip Code:06096-2345
Practice Address - Country:US
Practice Address - Phone:860-623-2601
Practice Address - Fax:860-370-5467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0094041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003404Medicaid