Provider Demographics
NPI:1609283704
Name:EDISON AMAZING SMILE DENTAL LLC
Entity Type:Organization
Organization Name:EDISON AMAZING SMILE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SURAIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAIKH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:240-328-5391
Mailing Address - Street 1:1907 OAK TREE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-2070
Mailing Address - Country:US
Mailing Address - Phone:732-549-0005
Mailing Address - Fax:
Practice Address - Street 1:1907 OAK TREE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-2070
Practice Address - Country:US
Practice Address - Phone:732-549-0005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025598001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty