=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619625589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TINY SMILES DENTISTRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2022
-----------------------------------------------------
Last Update Date | 03/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 GREEN ST
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07095-3066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-636-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 GLEN COVE RD
-----------------------------------------------------
City | ROSLYN HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11577-1732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-584-4906
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SETH NEWMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 917-584-4906
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------