Provider Demographics
NPI:1487943635
Name:WORCESTER SMILES YOUTH DENTISTRY, LLC
Entity type:Organization
Organization Name:WORCESTER SMILES YOUTH DENTISTRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, L & C
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-750-0343
Mailing Address - Street 1:16 ARCADE UNIT 198747
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1994
Mailing Address - Country:US
Mailing Address - Phone:615-750-0343
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:388 PARK AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-1025
Practice Address - Country:US
Practice Address - Phone:508-798-6565
Practice Address - Fax:508-798-6687
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WORCESTER SMILES YOUTH DENTISTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-28
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110088462AMedicaid