Provider Demographics
NPI:1568779007
Name:ADVANCED SMILE INSTITUTE, PA
Entity Type:Organization
Organization Name:ADVANCED SMILE INSTITUTE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-512-4125
Mailing Address - Street 1:1850 SW FOUNTAINVIEW BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1850 SW FOUNTAINVIEW BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3443
Practice Address - Country:US
Practice Address - Phone:772-336-9388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty