Provider Demographics
NPI:1669824082
Name:SUPER SMILE CENTER OF BETHESDA
Entity Type:Organization
Organization Name:SUPER SMILE CENTER OF BETHESDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMISHA
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHROFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-469-4775
Mailing Address - Street 1:10320 WESTLAKE DR
Mailing Address - Street 2:109
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-6448
Mailing Address - Country:US
Mailing Address - Phone:301-469-4775
Mailing Address - Fax:301-469-4776
Practice Address - Street 1:10320 WESTLAKE DR
Practice Address - Street 2:109
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-6448
Practice Address - Country:US
Practice Address - Phone:301-469-4775
Practice Address - Fax:301-469-4776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-09
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty