MEDICARE: SMBA DENTISTRY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1164999181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMBA DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	2801 MCRAE RD STE C1
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-3056
Country	:	US
Telephone Number	:	804-272-9079
Fax Number	:	804-272-9107

Provider Business Practice Location Address
First Line	:	2801 MCRAE RD STE C1
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-3056
Country	:	US
Telephone Number	:	804-272-9079
Fax Number	:	804-272-9107

Authorized Official
Title or Position	:	SOLE OWNER
Name	:	DR. SHIVANGI B AMIN
Credential	:	DDS, MS
Telephone Number	:	804-272-9079

Provider Enumeration Date	:	10/29/2018
Last Update Date	:	10/29/2018

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