Provider Demographics
NPI:1851852339
Name:CHEN, ISABELLA YIROA (DMD)
Entity Type:Individual
Prefix:
First Name:ISABELLA
Middle Name:YIROA
Last Name:CHEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 COLUMBUS AVENUE
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3000
Mailing Address - Fax:203-503-6515
Practice Address - Street 1:428 COLUMBUS AVENUE
Practice Address - Street 2:DENTAL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519
Practice Address - Country:US
Practice Address - Phone:203-503-3040
Practice Address - Fax:203-503-3187
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12497390200000X
CT128471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235893Medicaid