Provider Demographics
NPI:1679209340
Name:SMILE DENTAL REVERE LLC
Entity Type:Organization
Organization Name:SMILE DENTAL REVERE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:YANOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-284-2275
Mailing Address - Street 1:144 BROADWAY # 2
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-5349
Mailing Address - Country:US
Mailing Address - Phone:781-284-2275
Mailing Address - Fax:
Practice Address - Street 1:144 BROADWAY # 2
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-5349
Practice Address - Country:US
Practice Address - Phone:781-284-2275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-26
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty