=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073729794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDDSMILES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 NORTHERN BLVD
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-365-5439
-----------------------------------------------------
Fax | 516-365-5469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 NORTHERN BLVD SUITE 102
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-365-5439
-----------------------------------------------------
Fax | 516-365-5469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR DENTIST
-----------------------------------------------------
Name | MRS. MICHELE SAVEL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 516-365-5439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 0514621
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------