Basic Information
| Provider Information | |||||||||
| NPI: | 1427448877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIDDSMILES PEDIATRIC DENTISTRY 4 PLLC | ||||||||
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| OtherOrganizationName: | KIDDSMILES PEDIATRIC DENTISTRY 4 PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2211 MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | MERRICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115664752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163655439 | ||||||||
| FaxNumber: | 5164421020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | MERRICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115664752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163655439 | ||||||||
| FaxNumber: | 5164421020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2015 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | HUTTER | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | INSURANCE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6315764254 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.