Provider Demographics
NPI:1033622246
Name:MAGICLAND PEDIATRIC DENTAL LLC
Entity Type:Organization
Organization Name:MAGICLAND PEDIATRIC DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHIA HUI
Authorized Official - Middle Name:JENNY
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-453-4055
Mailing Address - Street 1:1011 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-2294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1301
Practice Address - Country:US
Practice Address - Phone:860-282-0630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0101101223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008004605Medicaid