MEDICARE: FRESHEST 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	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center

General Provider Information

NPI Number	:	1992584718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESHEST SMILES LLC

Provider Business Mailing Address
First Line	:	PO BOX 1097
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-1015
Country	:	US
Telephone Number	:	718-294-3725
Fax Number	:

Provider Business Practice Location Address
First Line	:	436 FORT WASHINGTON AVE APT 1B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10033-3533
Country	:	US
Telephone Number	:	718-294-3725
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALEJANDRO WILLIAMS
Credential	:	DDS
Telephone Number	:	718-294-3725

Provider Enumeration Date	:	09/22/2023
Last Update Date	:	09/22/2023

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