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General NPI Number Information
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NPI Number | 1164817870
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Entity Type | Organization
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Legal Business Name | I-SMILE BRACES, PLLC
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Dates
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Enumeration Date | 03/31/2015
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 150 ISLIP AVE SUITE 3
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City | ISLIP
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State | NY
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Zip | 11751-3222
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Country | US
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Telephone | 631-581-6565
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Fax | 631-581-6574
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Provider Business Mailing Address
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Address Line | 150 ISLIP AVE SUITE 3
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City | ISLIP
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State | NY
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Zip | 11751-3222
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Country | US
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Telephone | 631-581-6565
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Fax | 631-581-6574
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. CHANDRA PHAM
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Credential | DDS
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Telephone | 631-581-6565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 054700-1
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License Number State | NY
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