Provider Demographics
NPI:1083033773
Name:ORTHODONTICS AT JACKSON HEIGHTS SMILES, PLLC
Entity Type:Organization
Organization Name:ORTHODONTICS AT JACKSON HEIGHTS SMILES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAJU
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-235-9007
Mailing Address - Street 1:210 W 70TH ST
Mailing Address - Street 2:APT 1101
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-4304
Mailing Address - Country:US
Mailing Address - Phone:631-235-9007
Mailing Address - Fax:212-954-5583
Practice Address - Street 1:3062 79TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1510
Practice Address - Country:US
Practice Address - Phone:718-426-9400
Practice Address - Fax:718-426-9497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0507111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03128301Medicaid