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General NPI Number Information
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NPI Number | 1629433800
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Entity Type | Organization
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Legal Business Name | SUPREME SMILES OF SARASOTA
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Dates
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Enumeration Date | 12/15/2015
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Last Update Date | 12/15/2015
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Provider Practice Location Address
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Address Line | 2345 BEE RIDGE RD SUITE 4
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City | SARASOTA
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State | FL
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Zip | 34239-6251
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Country | US
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Telephone | 941-923-7060
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Fax | 941-925-4724
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Provider Business Mailing Address
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Address Line | 2345 BEE RIDGE RD SUITE 4
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City | SARASOTA
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State | FL
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Zip | 34239-6251
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Country | US
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Telephone | 941-923-7060
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Fax | 941-925-4724
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Authorized Official
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Title or Position | DENTIST
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Name | MELVIN MATHEW KORATTIYIL
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Credential | DMD
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Telephone | 941-923-7060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN18851
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License Number State | FL
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