Provider Demographics
NPI:1225717002
Name:SMILE DESTINATION, LLC
Entity Type:Organization
Organization Name:SMILE DESTINATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SMILE
Authorized Official - Middle Name:DESTINATION
Authorized Official - Last Name:LLC
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:302-357-5166
Mailing Address - Street 1:122 HONORA DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-2042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2603 EASTBURN CTR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7285
Practice Address - Country:US
Practice Address - Phone:302-357-5166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental