=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124585674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON SMILES DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41-51 WILSON AVE STE 2-D
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07105-3269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-589-7337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41-51 WILSON AVE STE 2-D
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07105-3269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-589-7337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. UMA KANIKICHARLA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 732-857-7247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------