Provider Demographics
NPI:1851581243
Name:BROCKTON SMILES YOUTH DENTISTRY, LLC
Entity Type:Organization
Organization Name:BROCKTON SMILES YOUTH DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, LICENSING & CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-750-0343
Mailing Address - Street 1:16 ARCADE UNIT 198747
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1994
Mailing Address - Country:US
Mailing Address - Phone:615-750-0343
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:70 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1811
Practice Address - Country:US
Practice Address - Phone:508-588-8090
Practice Address - Fax:508-588-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110077842AMedicaid