Provider Demographics
NPI:1063272136
Name:LI SMILE DESIGN DENTISTRY PC
Entity type:Organization
Organization Name:LI SMILE DESIGN DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PORFIRIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-388-5967
Mailing Address - Street 1:1750 5TH AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3438
Mailing Address - Country:US
Mailing Address - Phone:631-388-5967
Mailing Address - Fax:
Practice Address - Street 1:1750 5TH AVE STE 8
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-3438
Practice Address - Country:US
Practice Address - Phone:631-388-5967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty