Provider Demographics
NPI:1457579740
Name:IN STYLE SMILE DENTAL, PC
Entity Type:Organization
Organization Name:IN STYLE SMILE DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:AGAMOV
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-998-1178
Mailing Address - Street 1:1249 ASHLEY BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-1536
Mailing Address - Country:US
Mailing Address - Phone:508-998-1178
Mailing Address - Fax:508-995-1775
Practice Address - Street 1:1249 ASHLEY BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745-1536
Practice Address - Country:US
Practice Address - Phone:508-998-1178
Practice Address - Fax:508-995-1775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20247122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty