Provider Demographics
NPI:1144921602
Name:KID SMILES PEDIATRIC DENTISTRY OF PORT JEFFERSON STATION PLLC
Entity type:Organization
Organization Name:KID SMILES PEDIATRIC DENTISTRY OF PORT JEFFERSON STATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PASTORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-548-8753
Mailing Address - Street 1:1174 ROUTE 112 STE B
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8033
Mailing Address - Country:US
Mailing Address - Phone:631-676-4071
Mailing Address - Fax:516-588-9221
Practice Address - Street 1:1174 ROUTE 112 STE B
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8033
Practice Address - Country:US
Practice Address - Phone:631-676-4071
Practice Address - Fax:516-588-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty