=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881346427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY SMILE FOR LIFE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2022
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9173 ROOSEVELT BLVD STE 22
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19114-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-515-4797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 KINGSLEY CT
-----------------------------------------------------
City | NEWTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18940-2408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-666-7415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | VIJI SEETHARAMN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 732-666-7415
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------