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General NPI Number Information
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NPI Number | 1144921602
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Entity Type | Organization
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Legal Business Name | KID SMILES PEDIATRIC DENTISTRY OF PORT JEFFERSON STATION PLLC
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Dates
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Enumeration Date | 03/13/2023
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 1174 ROUTE 112 STE B
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-8033
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Country | US
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Telephone | 631-676-4071
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Fax | 516-588-9221
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Provider Business Mailing Address
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Address Line | 1174 ROUTE 112 STE B
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-8033
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Country | US
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Telephone | 631-676-4071
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Fax | 516-588-9221
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Authorized Official
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Title or Position | INSURANCE COORDINATOR
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Name | CYNTHIA LYNN PASTORE
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Credential |
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Telephone | 516-548-8753
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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