Provider Demographics
NPI:1386187714
Name:MOORESTOWN SMILE CENTER LLC
Entity Type:Organization
Organization Name:MOORESTOWN SMILE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-638-5266
Mailing Address - Street 1:740 MARNE HWY
Mailing Address - Street 2:SUIT 106
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3126
Mailing Address - Country:US
Mailing Address - Phone:856-638-5266
Mailing Address - Fax:856-638-5355
Practice Address - Street 1:740 MARNE HWY
Practice Address - Street 2:SUIT 106
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3126
Practice Address - Country:US
Practice Address - Phone:856-638-5266
Practice Address - Fax:856-638-5355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-03
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022823001223G0001X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1942370143OtherINDIVIUAL NPI