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General NPI Number Information
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NPI Number | 1295194363
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Entity Type | Organization
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Legal Business Name | SIMPLY SMILE DENTAL PC
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Dates
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Enumeration Date | 02/18/2016
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Last Update Date | 02/18/2016
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Provider Practice Location Address
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Address Line | 6222 MYRTLE AVE
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City | GLENDALE
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State | NY
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Zip | 11385-6236
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Country | US
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Telephone | 718-821-7432
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Fax |
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Provider Business Mailing Address
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Address Line | 4545 CENTER BLVD APT 2908
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City | LONG ISLAND CITY
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State | NY
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Zip | 11109-5960
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Country | US
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Telephone | 347-924-7736
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUAN CARLOS PORTELA
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Credential | DMD
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Telephone | 347-924-7736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 053665
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License Number State | NY
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