Healthcare Provider Details

I. General information

NPI: 1659280154
Provider Name (Legal Business Name): SMILE SPACE DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 ATLANTIC AVE UNIT 2
BROOKLYN NY
11217-4946
US

IV. Provider business mailing address

557 ATLANTIC AVE UNIT 2
BROOKLYN NY
11217-4946
US

V. Phone/Fax

Practice location:
  • Phone: 717-395-3144
  • Fax:
Mailing address:
  • Phone: 717-395-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. COREY LAVELLE BLACK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: DMD
Phone: 717-395-3144