=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134591795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE CARES FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2015
-----------------------------------------------------
Last Update Date | 10/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 BROADWAY SUITE #201
-----------------------------------------------------
City | PATTERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-433-4600
-----------------------------------------------------
Fax | 973-433-4601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 BROADWAY SUITE #201
-----------------------------------------------------
City | PATTERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-433-4600
-----------------------------------------------------
Fax | 973-433-4601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JYOTHI KALIMEREDDI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 973-997-6394
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22DI02422300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------