Organization
BROCKTON SMILES YOUTH DENTISTRY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JENELL STUMP (MANAGER, LICENSING & CREDENTIALING)
(615) 750-0343
Entity
Organization
Contact information
Practice address
70 WESTGATE DR, BROCKTON, MA 02301-1811
(508) 588-8090
(508) 588-8010
Mailing address
16 ARCADE UNIT 198747, NASHVILLE, TN 37219-1994
(615) 750-0343
(615) 986-1705
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110077842A
—
MA
Enumeration date
07/31/2007
Last updated
07/09/2014
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