Provider Demographics
NPI:1508574773
Name:PLYMOUTH SMILES DENTISTRY, PC
Entity Type:Organization
Organization Name:PLYMOUTH SMILES DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PARVATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:JITHENDRANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-390-2614
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:763-390-2414
Mailing Address - Fax:763-290-6811
Practice Address - Street 1:3405 VICKSBURG LN N STE 120
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1370
Practice Address - Country:US
Practice Address - Phone:763-390-2414
Practice Address - Fax:763-290-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty