Healthcare Provider Details

I. General information

NPI: 1982302964
Provider Name (Legal Business Name): CRYSTAL CLEAR ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 05/13/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 FOULK RD STE CANDD
WILMINGTON DE
19810-3700
US

IV. Provider business mailing address

1805 FOULK RD STE CANDD
WILMINGTON DE
19810-3700
US

V. Phone/Fax

Practice location:
  • Phone: 917-626-6920
  • Fax:
Mailing address:
  • Phone: 917-626-6920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. AESHA CHAUDHRY
Title or Position: DOCTOR
Credential: DMD
Phone: 917-626-6920