Provider Demographics
NPI:1326620196
Name:SMILE LOFT AFFINITY DENTAL LLC
Entity Type:Organization
Organization Name:SMILE LOFT AFFINITY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:VAIBHAV
Authorized Official - Middle Name:
Authorized Official - Last Name:RAI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-216-0339
Mailing Address - Street 1:4 E ROLLING XRDS STE 205
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-6281
Mailing Address - Country:US
Mailing Address - Phone:410-719-7900
Mailing Address - Fax:
Practice Address - Street 1:4 E ROLLING XRDS STE 205
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-6281
Practice Address - Country:US
Practice Address - Phone:410-719-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD046068200Medicaid