Provider Demographics
NPI:1811729569
Name:THE SMILE SPOT PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:THE SMILE SPOT PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRINBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-680-6915
Mailing Address - Street 1:188 E 64TH ST APT 1602
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 THIELLS MOUNT IVY RD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3021
Practice Address - Country:US
Practice Address - Phone:917-979-6579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03636202Medicaid