=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457315822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRACLE DENTAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 WALTER E FORAN BLVD SUITE 403
-----------------------------------------------------
City | FLEMINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08822-4664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-788-0088
-----------------------------------------------------
Fax | 908-788-0086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 WALTER E FORAN BLVD SUITE 403
-----------------------------------------------------
City | FLEMINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08822-4664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-788-0088
-----------------------------------------------------
Fax | 908-788-0086
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER/OWNER
-----------------------------------------------------
Name | DR. STEVEN YEE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 908-788-0088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22DI02029300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------