Provider Demographics
NPI:1497944458
Name:MAGIC SMILE DENTAL PC
Entity Type:Organization
Organization Name:MAGIC SMILE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YEFIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANIMOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:908-486-5000
Mailing Address - Street 1:515 N WOOD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-4173
Mailing Address - Country:US
Mailing Address - Phone:908-486-5000
Mailing Address - Fax:908-486-5006
Practice Address - Street 1:515 N WOOD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4173
Practice Address - Country:US
Practice Address - Phone:908-486-5000
Practice Address - Fax:908-486-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ230871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty