MEDICARE: SMALL SMILES DENTISTRY OF ROCHESTER, 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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	70491SS	OTHER	NY	EXCELLUS BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912916081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMALL SMILES DENTISTRY OF ROCHESTER, LLC

Provider Business Mailing Address
First Line	:	201 W 8TH ST
Second Line	:	SUITE 810
City	:	PUEBLO
State	:	CO
Zip	:	81003-3038
Country	:	US
Telephone Number	:	719-562-4447
Fax Number	:

Provider Business Practice Location Address
First Line	:	728 RIDGE RD E
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14621-1719
Country	:	US
Telephone Number	:	585-663-1624
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, LICENSING & CREDENTIALING
Name	:	MS. TRUDY WILLIAMS
Credential	:
Telephone Number	:	615-750-0342

Provider Enumeration Date	:	08/06/2006
Last Update Date	:	05/17/2010

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