Provider Demographics
NPI:1356898050
Name:SOUTH SHORE SMILES LLC
Entity type:Organization
Organization Name:SOUTH SHORE SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHIEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-716-1259
Mailing Address - Street 1:9270 WICKER AVE
Mailing Address - Street 2:SUITE E AND F
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8508
Mailing Address - Country:US
Mailing Address - Phone:219-627-3133
Mailing Address - Fax:
Practice Address - Street 1:9270 WICKER AVE
Practice Address - Street 2:SUITE E AND F
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8508
Practice Address - Country:US
Practice Address - Phone:219-627-3133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011456A1223P0221X
IN12011455A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1144540980Medicaid
IN1184944159Medicaid