NPIMap

Organization Active NPI

Worcester Smiles Youth Dentistry, LLC

  • General Practice Dentistry
  • Worcester, MA
National Provider Identifier
1073661385
Registry record updated Jul 9, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
WORCESTER SMILES YOUTH DENTISTRY, LLC
Practice address
290 Park Ave
Worcester, MA 01609-1805
Phone
(508) 798-9040
Fax
(508) 798-9060
NPI assigned
Jan 5, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Jenell Stump
Title
Manager, Licensing & Credentialing
Phone
(615) 750-0343

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X Primary

Addresses

Primary practice location

290 Park Ave
Worcester, MA 01609-1805

Mailing address

16 Arcade Unit 198747
Nashville, TN 37219-1994
Phone (615) 750-0343

Other identifiers 1

IdentifierTypeStateIssuer
110069690AMedicaidMA

National Provider Directory

National Provider Directory
Tax ID family
Worcester Smiles Youth Dentistry LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

290 Park Ave
Worcester, MA 01609
Phone (508) 798-9040

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167955200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1404864000000",
    "number": "1073661385",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16 ARCADE UNIT 198747",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372191994",
            "telephone_number": "615-750-0343",
            "fax_number": "615-986-1705"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "290 PARK AVE",
            "city": "WORCESTER",
            "state": "MA",
            "postal_code": "016091805",
            "telephone_number": "508-798-9040",
            "fax_number": "508-798-9060"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WORCESTER SMILES YOUTH DENTISTRY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-05",
        "last_updated": "2014-07-09",
        "status": "A",
        "authorized_official_last_name": "STUMP",
        "authorized_official_first_name": "JENELL",
        "authorized_official_title_or_position": "MANAGER, LICENSING & CREDENTIALING",
        "authorized_official_telephone_number": "615-750-0343",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "110069690A",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Worcester, MA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.