Provider Demographics
NPI:1033383740
Name:SMILE USA FOR RECONSTRUCTIVE DENTISTRY
Entity Type:Organization
Organization Name:SMILE USA FOR RECONSTRUCTIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:IYER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MDS
Authorized Official - Phone:908-527-8880
Mailing Address - Street 1:469 MORRIS AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-1967
Mailing Address - Country:US
Mailing Address - Phone:908-527-8880
Mailing Address - Fax:908-527-8587
Practice Address - Street 1:469 MORRIS AVE
Practice Address - Street 2:STE. 300
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1967
Practice Address - Country:US
Practice Address - Phone:908-527-8880
Practice Address - Fax:908-527-8587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10204811223G0001X
NJ192451223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7221509Medicaid