Provider Demographics
NPI:1598379851
Name:ELITE SMILES DENTAL GROUP LLC
Entity Type:Organization
Organization Name:ELITE SMILES DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANATOLIY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-524-5194
Mailing Address - Street 1:9 COVEY RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06013-1720
Mailing Address - Country:US
Mailing Address - Phone:850-524-5194
Mailing Address - Fax:
Practice Address - Street 1:9 COVEY RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06013-1720
Practice Address - Country:US
Practice Address - Phone:850-524-5194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-03
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment