Healthcare Provider Details

I. General information

NPI: 1063811230
Provider Name (Legal Business Name): EVERGROWING SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 E MAIN ST SUITE C
MOORESTOWN NJ
08057-3382
US

IV. Provider business mailing address

9 E MAIN ST SUITE C
MOORESTOWN NJ
08057-3382
US

V. Phone/Fax

Practice location:
  • Phone: 856-206-9255
  • Fax: 856-206-9254
Mailing address:
  • Phone: 856-206-9255
  • Fax: 856-206-9254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: E. A. STRANQUIST
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 856-206-9255