Healthcare Provider Details

I. General information

NPI: 1326720194
Provider Name (Legal Business Name): ISMILE ORTHODONTICS OF WATERBURY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 REIDVILLE DRIVE, SUITE A4
WATERBURY CT
06705-2650
US

IV. Provider business mailing address

464 REIDVILLE DRIVE, SUITE A4
WATERBURY CT
06705-2650
US

V. Phone/Fax

Practice location:
  • Phone: 203-601-6423
  • Fax: 203-575-8399
Mailing address:
  • Phone: 203-601-6423
  • Fax: 203-575-8399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. EFSTATHIOS GIANNOUTSOS
Title or Position: OWNER
Credential: DDS
Phone: 917-518-9128