Provider Demographics
NPI:1396492898
Name:THE SMILE STORE-PALM BEACH GARDENS, P.A.
Entity type:Organization
Organization Name:THE SMILE STORE-PALM BEACH GARDENS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAVASTANO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:561-658-4100
Mailing Address - Street 1:4362 NORTHLAKE BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6269
Mailing Address - Country:US
Mailing Address - Phone:561-658-4100
Mailing Address - Fax:866-333-2309
Practice Address - Street 1:4362 NORTHLAKE BLVD STE 114
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6269
Practice Address - Country:US
Practice Address - Phone:561-658-4100
Practice Address - Fax:866-333-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105737100Medicaid
FL1154348233OtherTYPE 1 NPI PROVIDER ID DR. SAVASTANO
FL1518505692OtherNPI 2 OF OLD TIN/LLC NAME FOR SAME DOCTOR, SAME LOCATION
FLDN15487OtherDENTAL LICENSE