Provider Demographics
NPI:1740602846
Name:PURA VIDA SMILES, PC
Entity Type:Organization
Organization Name:PURA VIDA SMILES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRM
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTOLLINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-273-8204
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:866-273-8204
Mailing Address - Fax:866-803-4943
Practice Address - Street 1:1113 BOARDMAN RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1901
Practice Address - Country:US
Practice Address - Phone:517-768-8100
Practice Address - Fax:517-780-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty