1760558894 NPI number — INDIAN VALLEY DENTAL ASSOCIATES

Table of content: (NPI 1760558894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760558894 NPI number — INDIAN VALLEY DENTAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN VALLEY DENTAL ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1760558894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 E BROAD ST
Provider Second Line Business Mailing Address:
SUITE #200
Provider Business Mailing Address City Name:
SOUDERTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18964-1263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-723-5531
Provider Business Mailing Address Fax Number:
215-721-9119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 E BROAD ST
Provider Second Line Business Practice Location Address:
SUITE #200
Provider Business Practice Location Address City Name:
SOUDERTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18964-1263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-723-5531
Provider Business Practice Location Address Fax Number:
215-721-9119
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROSSMAN
Authorized Official First Name:
SPENCER
Authorized Official Middle Name:
JARED
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-704-4546

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DS021793L , 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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