Provider Demographics
NPI:1164861266
Name:SMILE ZONE DENTISTRY, PORT JERVIS PC
Entity type:Organization
Organization Name:SMILE ZONE DENTISTRY, PORT JERVIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:BAJAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-874-2243
Mailing Address - Street 1:26 FOWLER ST
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-2534
Mailing Address - Country:US
Mailing Address - Phone:845-856-6721
Mailing Address - Fax:
Practice Address - Street 1:26 FOWLER ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2534
Practice Address - Country:US
Practice Address - Phone:845-856-6721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049729-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty