Provider Demographics
NPI:1336398676
Name:ADVANCED COSMETIC DENTISTRY LTD
Entity Type:Organization
Organization Name:ADVANCED COSMETIC DENTISTRY LTD
Other - Org Name:PERIODONTOLOGY ASSOCIATES LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:401-943-6311
Mailing Address - Street 1:1090 NEW LONDON AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-3035
Mailing Address - Country:US
Mailing Address - Phone:401-943-6311
Mailing Address - Fax:401-943-2030
Practice Address - Street 1:1090 NEW LONDON AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-3035
Practice Address - Country:US
Practice Address - Phone:401-943-6311
Practice Address - Fax:401-943-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty