=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184949802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAUTIFUL SMILES DENTAL ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2010
-----------------------------------------------------
Last Update Date | 04/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1212 6TH AVE FL 4
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10036-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-997-0203
-----------------------------------------------------
Fax | 212-624-0289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1212 6TH AVE FL 4
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10036-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-997-0203
-----------------------------------------------------
Fax | 212-624-0289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. IRINA REYZELMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 212-997-0203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------