Healthcare Provider Details

I. General information

NPI: 1487943635
Provider Name (Legal Business Name): WORCESTER SMILES YOUTH DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 PARK AVE
WORCESTER MA
01610-1025
US

IV. Provider business mailing address

16 ARCADE UNIT 198747
NASHVILLE TN
37219-1994
US

V. Phone/Fax

Practice location:
  • Phone: 508-798-6565
  • Fax: 508-798-6687
Mailing address:
  • Phone: 615-750-0343
  • Fax: 615-986-1705

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: MRS. JENELL STUMP
Title or Position: MANAGER, L & C
Credential:
Phone: 615-750-0343