Healthcare Provider Details

I. General information

NPI: 1831766211
Provider Name (Legal Business Name): BROAD SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2021
Last Update Date: 06/05/2021
Certification Date: 06/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LORING AVE STE 8
SALEM MA
01970-4264
US

IV. Provider business mailing address

600 LORING AVE STE 8
SALEM MA
01970-4264
US

V. Phone/Fax

Practice location:
  • Phone: 978-910-0004
  • Fax:
Mailing address:
  • Phone: 978-910-0004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. HUBERT J PARK
Title or Position: PRESIDENT
Credential: DMD, MPH
Phone: 617-895-6700