Provider Demographics
NPI:1265838379
Name:WALLINGFORD SMILEMAKERS LLC
Entity Type:Organization
Organization Name:WALLINGFORD SMILEMAKERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-874-5700
Mailing Address - Street 1:1 CHESTER RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19086-6601
Mailing Address - Country:US
Mailing Address - Phone:610-874-5700
Mailing Address - Fax:610-872-5348
Practice Address - Street 1:1 CHESTER RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:PA
Practice Address - Zip Code:19086-6601
Practice Address - Country:US
Practice Address - Phone:610-874-5700
Practice Address - Fax:610-872-5348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028517L261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7370300001OtherMEDICARE PCAN