Healthcare Provider Details

I. General information

NPI: 1720655491
Provider Name (Legal Business Name): SHAN SHAN CEN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 07/12/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SUMMIT AVE
HACKENSACK NJ
07601-1218
US

IV. Provider business mailing address

17 SUMMIT AVE
HACKENSACK NJ
07601-1218
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-0770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02848900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: