Provider Demographics
NPI:1902663933
Name:STELLAR SMILES FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:STELLAR SMILES FAMILY DENTAL LLC
Other - Org Name:HATHORNE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEERTHY
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:CHILAKAMARRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-606-2148
Mailing Address - Street 1:491 MAPLE ST STE 302
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-4026
Mailing Address - Country:US
Mailing Address - Phone:703-953-4088
Mailing Address - Fax:
Practice Address - Street 1:491 MAPLE ST STE 302
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-4026
Practice Address - Country:US
Practice Address - Phone:703-953-4088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN1857756OtherLICENSE NUMBER