Provider Demographics
NPI:1740603000
Name:BEAUTIFUL SMILES ELBRIDGE, LLC
Entity type:Organization
Organization Name:BEAUTIFUL SMILES ELBRIDGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:NANGLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-277-5039
Mailing Address - Street 1:239 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:13060-8706
Mailing Address - Country:US
Mailing Address - Phone:315-277-5039
Mailing Address - Fax:315-277-5039
Practice Address - Street 1:239 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:13060-8706
Practice Address - Country:US
Practice Address - Phone:315-277-5039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0385411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00842439Medicaid