Provider Demographics
NPI:1124585674
Name:WILSON SMILES DENTAL LLC
Entity Type:Organization
Organization Name:WILSON SMILES DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:UMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANIKICHARLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-857-7247
Mailing Address - Street 1:41-51 WILSON AVE STE 2-D
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3269
Mailing Address - Country:US
Mailing Address - Phone:973-589-7337
Mailing Address - Fax:
Practice Address - Street 1:41-51 WILSON AVE STE 2-D
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3269
Practice Address - Country:US
Practice Address - Phone:973-589-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental