Healthcare Provider Details

I. General information

NPI: 1275008138
Provider Name (Legal Business Name): GRACE DENTAL SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 ROUTE 109
WEST BABYLON NY
11704-6220
US

IV. Provider business mailing address

102 ROUTE 109
WEST BABYLON NY
11704-6220
US

V. Phone/Fax

Practice location:
  • Phone: 631-619-0010
  • Fax: 631-983-4774
Mailing address:
  • Phone: 631-619-0010
  • Fax: 631-983-4774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AVINASH CHERIAN
Title or Position: OWNER
Credential: DMD
Phone: 631-619-0010