Provider Demographics
NPI:1710130455
Name:IDEALSMILE
Entity Type:Organization
Organization Name:IDEALSMILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAE
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-257-7374
Mailing Address - Street 1:2501 WHITTLESEY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-3031
Mailing Address - Country:US
Mailing Address - Phone:706-257-7374
Mailing Address - Fax:706-257-7379
Practice Address - Street 1:2501 WHITTLESEY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-3031
Practice Address - Country:US
Practice Address - Phone:706-257-7374
Practice Address - Fax:706-257-7379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013040261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA561235509CMedicaid
GA626075029CMedicaid