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General NPI Number Information
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NPI Number | 1437526308
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Entity Type | Organization
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Legal Business Name | SMILE NATION
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Dates
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Enumeration Date | 08/27/2015
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Last Update Date | 08/27/2015
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Provider Practice Location Address
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Address Line | 6060 53RD AVE E SUITE A
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City | BRADENTON
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State | FL
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Zip | 34203-9719
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Country | US
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Telephone | 941-727-0025
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Fax | 941-739-2315
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Provider Business Mailing Address
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Address Line | 6060 53RD AVE E SUITE A
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City | BRADENTON
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State | FL
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Zip | 34203-9719
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Country | US
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Telephone | 941-727-0025
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Fax | 941-739-2315
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Authorized Official
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Title or Position | PRESIDENT
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Name | DEREK M BUSCIGLIO
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Credential | DMD
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Telephone | 813-465-8289
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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 | DN14677
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License Number State | FL
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