Healthcare Provider Details

I. General information

NPI: 1215375365
Provider Name (Legal Business Name): SMILE KRAFTERS PEDIATRIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 S CEDAR CREST BLVD
ALLENTOWN PA
18103-6298
US

IV. Provider business mailing address

1247 S CEDAR CREST BLVD
ALLENTOWN PA
18103-6298
US

V. Phone/Fax

Practice location:
  • Phone: 610-628-1228
  • Fax:
Mailing address:
  • Phone: 610-628-1228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS036490
License Number StatePA

VIII. Authorized Official

Name: ANDREW DORMESHIAN
Title or Position: OWNER
Credential:
Phone: 917-847-6976