Healthcare Provider Details

I. General information

NPI: 1467925529
Provider Name (Legal Business Name): ADVANCED DENTISTRY OF RHODE ISLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 WAMPANOAG TRL STE 103
RIVERSIDE RI
02915-2215
US

IV. Provider business mailing address

250 WAMPANOAG TRL STE 103
RIVERSIDE RI
02915-2215
US

V. Phone/Fax

Practice location:
  • Phone: 401-434-4413
  • Fax:
Mailing address:
  • Phone: 401-434-4413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: RYAN S LEE
Title or Position: PRESIDENT
Credential:
Phone: 617-833-0158