Provider Demographics
NPI:1457873895
Name:SMILE LINE PC
Entity Type:Organization
Organization Name:SMILE LINE PC
Other - Org Name:RIVERDALE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:419-450-2211
Mailing Address - Street 1:20 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1638
Mailing Address - Country:US
Mailing Address - Phone:419-450-2211
Mailing Address - Fax:
Practice Address - Street 1:1073 RIVERDALE ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-4614
Practice Address - Country:US
Practice Address - Phone:413-285-7114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-07
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9211482Medicaid