Basic Information
| Provider Information | |||||||||
| NPI: | 1407903750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAWRENCE SMILES YOUTH DENTISTRY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 ARCADE UNIT 198747 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372191994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157500343 | ||||||||
| FaxNumber: | 6159861705 | ||||||||
| Practice Location | |||||||||
| Address1: | 73C WINTHROP AVE | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018433716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787256525 | ||||||||
| FaxNumber: | 9787256550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | STUMP | ||||||||
| AuthorizedOfficialFirstName: | JENELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6157500343 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 110069905A | 05 | MA | MEDICAID | 3079920 | 05 | NH | MEDICAID |