Provider Demographics
NPI:1225368509
Name:SERENITY DENTAL SPA, PA
Entity Type:Organization
Organization Name:SERENITY DENTAL SPA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:DEMONT
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-805-2401
Mailing Address - Street 1:150 E HIGHWAY 67
Mailing Address - Street 2:SUITE 190
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-4411
Mailing Address - Country:US
Mailing Address - Phone:860-805-2401
Mailing Address - Fax:
Practice Address - Street 1:150 E HIGHWAY 67
Practice Address - Street 2:SUITE 190
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-4411
Practice Address - Country:US
Practice Address - Phone:860-805-2401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00246551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty