Provider Demographics
NPI:1730412701
Name:MY SMILE DENTISTRY
Entity type:Organization
Organization Name:MY SMILE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-928-2490
Mailing Address - Street 1:846 SOUTH OSPREY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236
Mailing Address - Country:US
Mailing Address - Phone:941-706-1505
Mailing Address - Fax:941-554-8172
Practice Address - Street 1:846 SOUTH OSPREY AVENUE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236
Practice Address - Country:US
Practice Address - Phone:941-706-1505
Practice Address - Fax:941-554-8172
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY SMILE DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18531122300000X
FLDN17733122300000X
FLDN18201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty