Provider Demographics
NPI:1689438079
Name:LASTING SMILE DENTAL
Entity Type:Organization
Organization Name:LASTING SMILE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TELLO-ABED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-838-9698
Mailing Address - Street 1:57850 VAN DYKE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48094-3827
Mailing Address - Country:US
Mailing Address - Phone:586-207-1091
Mailing Address - Fax:
Practice Address - Street 1:57850 VAN DYKE RD STE 500
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48094-3827
Practice Address - Country:US
Practice Address - Phone:586-207-1091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-07
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental