Provider Demographics
NPI:1740319656
Name:SMILES ON BROADWAY DENTAL CARE, PLLC
Entity type:Organization
Organization Name:SMILES ON BROADWAY DENTAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIZZIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-599-0883
Mailing Address - Street 1:116 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1635
Mailing Address - Country:US
Mailing Address - Phone:516-599-0883
Mailing Address - Fax:516-599-0227
Practice Address - Street 1:116 BROADWAY
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-1635
Practice Address - Country:US
Practice Address - Phone:516-599-0883
Practice Address - Fax:516-599-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty