Provider Demographics
NPI:1003219536
Name:ISMILE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:ISMILE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:SOO JIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-374-1558
Mailing Address - Street 1:22 N WASHINGTON AVE.
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621
Mailing Address - Country:US
Mailing Address - Phone:201-374-1558
Mailing Address - Fax:201-374-1559
Practice Address - Street 1:22 N WASHINGTON AVE.
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621
Practice Address - Country:US
Practice Address - Phone:201-374-1558
Practice Address - Fax:201-374-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02584500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty