1811345275 NPI number — INNOVATIVE DENTAL SERVICES, P.C.

Table of content: CHRISTOPHER SCOTT MANVEL LPC (NPI 1972186252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811345275 NPI number — INNOVATIVE DENTAL SERVICES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE DENTAL SERVICES, P.C.
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:
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:
1811345275
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1535 SWEETBRIAR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMISON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18929-1653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-275-6313
Provider Business Mailing Address Fax Number:
215-695-5511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5737 N BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19141-2307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-275-6313
Provider Business Practice Location Address Fax Number:
215-695-5511
Provider Enumeration Date:
05/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KANDOV
Authorized Official First Name:
OLGA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-275-6313

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DS037628 , 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)





Copyright © 2007-2025 www.npivalidator.com