=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942911524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRATFORD SMILES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2022
-----------------------------------------------------
Last Update Date | 12/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2945 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-4978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-375-3068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2945 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-4978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. YUCHEN SHENG
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 215-703-8680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------