Provider Demographics
NPI:1013472414
Name:SMILES ON THE GO RDH, LLC
Entity Type:Organization
Organization Name:SMILES ON THE GO RDH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-380-0830
Mailing Address - Street 1:653 COLLEGE HWY
Mailing Address - Street 2:P.O. BOX 885
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077-0885
Mailing Address - Country:US
Mailing Address - Phone:860-380-0830
Mailing Address - Fax:
Practice Address - Street 1:1 CHELSEA LN
Practice Address - Street 2:
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026-9634
Practice Address - Country:US
Practice Address - Phone:860-380-0830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-10
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental