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General NPI Number Information
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NPI Number | 1588058077
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Entity Type | Organization
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Legal Business Name | REVITALIZING SMILES, LLC
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Dates
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Enumeration Date | 03/24/2015
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Last Update Date | 03/24/2015
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Provider Practice Location Address
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Address Line | 2226 BLACK ROCK TPKE
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City | FAIRFIELD
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State | CT
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Zip | 06825-3240
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Country | US
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Telephone | 203-332-9049
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Fax | 203-366-6287
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Provider Business Mailing Address
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Address Line | 2226 BLACK ROCK TPKE
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City | FAIRFIELD
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State | CT
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Zip | 06825-3240
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Country | US
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Telephone | 203-332-9049
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Fax | 203-366-6287
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Authorized Official
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Title or Position | MANAGER
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Name | JUDITH HORBLITT
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Credential |
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Telephone | 203-332-9049
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 11048
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License Number State | CT
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