MEDICARE: DENT-AL SMILES, LLC

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	261QD0000X	Dental Clinic/Center	30020814	OH

General Provider Information

NPI Number	:	1720510001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENT-AL SMILES, LLC

Provider Business Mailing Address
First Line	:	1115 HICKS BLVD
Second Line	:	# 3
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-2889
Country	:	US
Telephone Number	:	412-779-4235
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 HICKS BLVD
Second Line	:	# 3
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-2889
Country	:	US
Telephone Number	:	412-779-4235
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALVARO R LAZO
Credential	:	DMD
Telephone Number	:	412-779-4235

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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