Provider Demographics
NPI:1851896567
Name:CENTRAL SQUARE SMILES DENTISTRY
Entity Type:Organization
Organization Name:CENTRAL SQUARE SMILES DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:315-638-0276
Mailing Address - Street 1:653 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036
Mailing Address - Country:US
Mailing Address - Phone:315-668-6261
Mailing Address - Fax:
Practice Address - Street 1:653 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036
Practice Address - Country:US
Practice Address - Phone:315-668-6261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA