Basic Information
| Provider Information | |||||||||
| NPI: | 1063542587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISMAEL | ||||||||
| FirstName: | KHADIJAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 103 BORMAN AVE | ||||||||
| Address2: | |||||||||
| City: | AVENEL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070012106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739796144 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21 QUITMAN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071034105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734244329 | ||||||||
| FaxNumber: | 9738242097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 22DI02314800 | NJ | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0097845 | 05 | NJ | MEDICAID | 0097829 | 05 | NJ | MEDICAID | 0097837 | 05 | NJ | MEDICAID |