Provider Demographics
NPI:1982889747
Name:SMILE INITIATIVE LLC
Entity Type:Organization
Organization Name:SMILE INITIATIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:DURANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-775-1525
Mailing Address - Street 1:1 KENDALL SQ
Mailing Address - Street 2:263
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1562
Mailing Address - Country:US
Mailing Address - Phone:617-775-1525
Mailing Address - Fax:
Practice Address - Street 1:1 KENDALL SQ
Practice Address - Street 2:263
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1562
Practice Address - Country:US
Practice Address - Phone:617-775-1525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-29
Last Update Date:2007-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20386261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental