Healthcare Provider Details

I. General information

NPI: 1326189820
Provider Name (Legal Business Name): KIDS SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 ISLAND AVE SUITE 210
PHILADELPHIA PA
19153-2300
US

IV. Provider business mailing address

2821 ISLAND AVE SUITE 210
PHILADELPHIA PA
19153-2300
US

V. Phone/Fax

Practice location:
  • Phone: 215-492-9291
  • Fax: 215-492-5856
Mailing address:
  • Phone: 215-492-9291
  • Fax: 215-492-5856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS035558
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS035389
License Number StatePA

VIII. Authorized Official

Name: NONI MASTRA
Title or Position: FINANCIAL DIRECTOR
Credential:
Phone: 215-492-9291