Provider Demographics
NPI:1457899379
Name:SMILE LI DENTISTRY LLC
Entity Type:Organization
Organization Name:SMILE LI DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-287-9300
Mailing Address - Street 1:8 SGT HARTZ DR
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1813
Mailing Address - Country:US
Mailing Address - Phone:646-287-9300
Mailing Address - Fax:
Practice Address - Street 1:525 WANAQUE AVE
Practice Address - Street 2:STE 101
Practice Address - City:POMPTON LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07442-1843
Practice Address - Country:US
Practice Address - Phone:646-287-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-11
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02496000122300000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No122300000XDental ProvidersDentistGroup - Multi-Specialty