Provider Demographics
NPI:1063542587
Name:ISMAEL, KHADIJAH (DMD)
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:ISMAEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-2106
Mailing Address - Country:US
Mailing Address - Phone:973-979-6144
Mailing Address - Fax:
Practice Address - Street 1:21 QUITMAN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-4105
Practice Address - Country:US
Practice Address - Phone:973-424-4329
Practice Address - Fax:973-824-2097
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI023148001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0097845Medicaid
NJ0097829Medicaid
NJ0097837Medicaid
NJ0097837Medicaid