Provider Demographics
NPI:1184318586
Name:SMILE LOFT FAIR LAWN, LLC
Entity type:Organization
Organization Name:SMILE LOFT FAIR LAWN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AR
Authorized Official - Prefix:
Authorized Official - First Name:OXANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYSKAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-545-2557
Mailing Address - Street 1:32-16 BROADWAY STE 201
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-4600
Mailing Address - Country:US
Mailing Address - Phone:201-794-0440
Mailing Address - Fax:
Practice Address - Street 1:32-16 BROADWAY STE 201
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-4600
Practice Address - Country:US
Practice Address - Phone:201-794-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-07
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty