Provider Demographics
NPI:1295398881
Name:JUNIOR SMILES LLC
Entity Type:Organization
Organization Name:JUNIOR SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-839-5228
Mailing Address - Street 1:4183 NW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073
Mailing Address - Country:US
Mailing Address - Phone:860-515-8433
Mailing Address - Fax:
Practice Address - Street 1:8223 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071
Practice Address - Country:US
Practice Address - Phone:954-507-0015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01544500Medicaid