=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841849965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODROW LITTLE SMILES FAMILY DENTISTRY P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2019
-----------------------------------------------------
Last Update Date | 09/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 739 WOODROW ROAD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-317-8524
-----------------------------------------------------
Fax | 347-507-2245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7001 AMBOY ROAD SUITE #113
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-317-8524
-----------------------------------------------------
Fax | 347-507-2245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST/OWNER
-----------------------------------------------------
Name | WILLIAM G. CORBETT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 718-317-8524
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------