Healthcare Provider Details

I. General information

NPI: 1760992432
Provider Name (Legal Business Name): GRACIOUS SMILES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MARKET ST.
CAMDEN NJ
08102
US

IV. Provider business mailing address

121 MARKET ST.
CAMDEN NJ
08102
US

V. Phone/Fax

Practice location:
  • Phone: 609-744-1200
  • Fax: 856-983-9003
Mailing address:
  • Phone: 609-744-1200
  • Fax: 856-983-9003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDI19272
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDI19272
License Number StateNJ

VIII. Authorized Official

Name: DR. MELBA PATRICIA BONELLI
Title or Position: CEO
Credential: DMD
Phone: 609-923-5730