Provider Demographics
NPI:1831766211
Name:BROAD SMILES LLC
Entity type:Organization
Organization Name:BROAD SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HUBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:617-895-6700
Mailing Address - Street 1:600 LORING AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-4264
Mailing Address - Country:US
Mailing Address - Phone:978-910-0004
Mailing Address - Fax:
Practice Address - Street 1:600 LORING AVE STE 8
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-4264
Practice Address - Country:US
Practice Address - Phone:978-910-0004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty