Provider Demographics
NPI:1548666142
Name:AWESOME SMILES
Entity type:Organization
Organization Name:AWESOME SMILES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-456-4789
Mailing Address - Street 1:1100 BARNUM AVE
Mailing Address - Street 2:BARNUM DENTAL
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1163 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-1620
Practice Address - Country:US
Practice Address - Phone:203-540-5577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-08
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10815122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty