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General NPI Number Information
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NPI Number | 1073987301
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Entity Type | Organization
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Legal Business Name | DYNAMIC SMILE DENTAL PLLC
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Dates
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Enumeration Date | 11/24/2015
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Last Update Date | 11/24/2015
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Provider Practice Location Address
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Address Line | 80 BOWERY ROOM #400
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City | NEW YORK
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State | NY
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Zip | 10013-4614
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Country | US
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Telephone | 212-219-8230
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Fax |
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Provider Business Mailing Address
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Address Line | 80 BOWERY ROOM #400
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City | NEW YORK
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State | NY
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Zip | 10013-4614
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Country | US
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Telephone | 212-219-8230
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Fax |
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | DIANA LEE
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Credential | DDS
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Telephone | 212-219-8230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 051245
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License Number State | NY
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