Provider Demographics
NPI:1275919656
Name:GREAT SMILE DENTAL SERVICES PC
Entity Type:Organization
Organization Name:GREAT SMILE DENTAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-795-9519
Mailing Address - Street 1:629 W 185TH ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3102
Mailing Address - Country:US
Mailing Address - Phone:212-795-9519
Mailing Address - Fax:646-353-6482
Practice Address - Street 1:629 W 185TH ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3102
Practice Address - Country:US
Practice Address - Phone:212-795-9519
Practice Address - Fax:646-353-6482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050561-1332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02387915Medicaid