Provider Demographics
NPI:1336514132
Name:AFFORDABLE SMILES, INC.
Entity Type:Organization
Organization Name:AFFORDABLE SMILES, INC.
Other - Org Name:AFFORDABLE SMILES MEADVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HITCHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-333-6000
Mailing Address - Street 1:900 WATER ST
Mailing Address - Street 2:SUITE 16
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3428
Mailing Address - Country:US
Mailing Address - Phone:814-333-6000
Mailing Address - Fax:814-333-6001
Practice Address - Street 1:900 WATER ST
Practice Address - Street 2:SUITE 16
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3428
Practice Address - Country:US
Practice Address - Phone:814-333-6000
Practice Address - Fax:814-333-6001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AFFORDABLE SMILES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035205122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028886400001Medicaid