MEDICARE: AUTHENTIC SMILES LLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1679013361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTHENTIC SMILES LLC

Provider Business Mailing Address
First Line	:	59 TURNPIKE SQ
Second Line	:
City	:	MILFORD
State	:	CT
Zip	:	06460-2758
Country	:	US
Telephone Number	:	203-876-6161
Fax Number	:

Provider Business Practice Location Address
First Line	:	59 TURNPIKE SQ
Second Line	:
City	:	MILFORD
State	:	CT
Zip	:	06460-2758
Country	:	US
Telephone Number	:	203-876-6161
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GREG BUSCH
Credential	:
Telephone Number	:	917-301-7666

Provider Enumeration Date	:	03/01/2017
Last Update Date	:	03/01/2017

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Directions to “AUTHENTIC SMILES LLC ” Practice Location

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