1467864637 NPI number — DR. KAUSHIK HARIDUTT SHARMA BDS, DMD, MPA

Table of content: MRS. SHANNON E TILLMAN CMA (NPI 1245965144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467864637 NPI number — DR. KAUSHIK HARIDUTT SHARMA BDS, DMD, MPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHARMA
Provider First Name:
KAUSHIK
Provider Middle Name:
HARIDUTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
BDS, DMD, MPA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467864637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3223 N BROAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19140-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-737-7547
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E LEHIGH AVE
Provider Second Line Business Practice Location Address:
PM2
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19125-1012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-737-7547
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DS040210 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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