=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184280620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOTHAM SMILES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2019
-----------------------------------------------------
Last Update Date | 05/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 157 EAST 32ND STREET SUITE B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-772-8387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 W 13TH ST APT 7FS
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-7936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-970-4835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. LEO J BLAIS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 347-772-8387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------