Provider Demographics
NPI:1548822786
Name:SMILES ON THE CANAL DENTISTRY
Entity type:Organization
Organization Name:SMILES ON THE CANAL DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYBELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-223-5480
Mailing Address - Street 1:124 FAIRPORT VILLAGE LNDG
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1804
Mailing Address - Country:US
Mailing Address - Phone:585-223-5480
Mailing Address - Fax:
Practice Address - Street 1:124 FAIRPORT VILLAGE LNDG
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1804
Practice Address - Country:US
Practice Address - Phone:585-223-5480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty