Provider Demographics
NPI:1952419855
Name:ABOUT YOUR SMILE PC
Entity Type:Organization
Organization Name:ABOUT YOUR SMILE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-734-0115
Mailing Address - Street 1:6776 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082
Mailing Address - Country:US
Mailing Address - Phone:610-734-0015
Mailing Address - Fax:610-734-1419
Practice Address - Street 1:6776 MARKET ST
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082
Practice Address - Country:US
Practice Address - Phone:610-734-0015
Practice Address - Fax:610-734-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
401786OtherUNITED CONCORDIA
PA0009098000001Medicaid