Provider Demographics
NPI:1205685724
Name:DYNAMIC SMILES ORTHODONTICS
Entity type:Organization
Organization Name:DYNAMIC SMILES ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:LEDJO
Authorized Official - Middle Name:
Authorized Official - Last Name:PALO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-695-2548
Mailing Address - Street 1:315 CENTER ROCK GRN STE 10
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06478-3174
Mailing Address - Country:US
Mailing Address - Phone:203-828-1088
Mailing Address - Fax:
Practice Address - Street 1:315 CENTER ROCK GRN STE 10
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:CT
Practice Address - Zip Code:06478-3174
Practice Address - Country:US
Practice Address - Phone:203-828-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-16
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty