Provider Demographics
NPI:1336590132
Name:SMILEVANA
Entity Type:Organization
Organization Name:SMILEVANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KANDIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-294-6168
Mailing Address - Street 1:690 DEPOT ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:690 DEPOT ST
Practice Address - Street 2:UNIT 3
Practice Address - City:EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356
Practice Address - Country:US
Practice Address - Phone:508-238-2924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856022261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental