Provider Demographics
NPI:1912483538
Name:IDEAL SMILE DENTAL
Entity Type:Organization
Organization Name:IDEAL SMILE DENTAL
Other - Org Name:IDEAL SMILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETGH
Authorized Official - Middle Name:MQ
Authorized Official - Last Name:LO PICCOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-859-5555
Mailing Address - Street 1:3200 BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-2118
Mailing Address - Country:US
Mailing Address - Phone:215-859-5555
Mailing Address - Fax:215-757-2457
Practice Address - Street 1:3200 BRISTOL RD
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-2118
Practice Address - Country:US
Practice Address - Phone:215-859-5555
Practice Address - Fax:215-757-2457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty