Provider Demographics
NPI:1326189820
Name:KIDS SMILES
Entity Type:Organization
Organization Name:KIDS SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NONI
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-492-9291
Mailing Address - Street 1:2821 ISLAND AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-2300
Mailing Address - Country:US
Mailing Address - Phone:215-492-9291
Mailing Address - Fax:215-492-5856
Practice Address - Street 1:2821 ISLAND AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19153-2300
Practice Address - Country:US
Practice Address - Phone:215-492-9291
Practice Address - Fax:215-492-5856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0353891223G0001X
PADS0355581223G0001X
PA1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018280190001Medicaid