Provider Demographics
NPI:1992294979
Name:SMILE DESIGN BOSTON
Entity type:Organization
Organization Name:SMILE DESIGN BOSTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:HASHEM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-840-0627
Mailing Address - Street 1:15 WAVERLY ST APT 260
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-1245
Mailing Address - Country:US
Mailing Address - Phone:617-840-0627
Mailing Address - Fax:
Practice Address - Street 1:21 CUSTOM HOUSE ST STE 110
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-3525
Practice Address - Country:US
Practice Address - Phone:617-840-0627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-06
Last Update Date:2018-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18567401223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487727301OtherDELTA DENTAL PREMIER
1487727301OtherBLUE CROSS BLUE SHIELD DENTAL