MEDICARE: SMILES ON THE CANAL DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1548822786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILES ON THE CANAL DENTISTRY

Provider Business Mailing Address
First Line	:	124 FAIRPORT VILLAGE LNDG
Second Line	:
City	:	FAIRPORT
State	:	NY
Zip	:	14450-1804
Country	:	US
Telephone Number	:	585-223-5480
Fax Number	:

Provider Business Practice Location Address
First Line	:	124 FAIRPORT VILLAGE LNDG
Second Line	:
City	:	FAIRPORT
State	:	NY
Zip	:	14450-1804
Country	:	US
Telephone Number	:	585-223-5480
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	DAMIAN GRAYBELLE
Credential	:
Telephone Number	:	585-223-5480

Provider Enumeration Date	:	07/08/2019
Last Update Date	:	07/08/2019

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Directions to “SMILES ON THE CANAL DENTISTRY ” Practice Location

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