Healthcare Provider Details

I. General information

NPI: 1124521646
Provider Name (Legal Business Name): COLLINGDALE DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2018
Last Update Date: 03/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 CLIFTON AVE
COLLINGDALE PA
19023-3712
US

IV. Provider business mailing address

224 CLIFTON AVE
COLLINGDALE PA
19023-3712
US

V. Phone/Fax

Practice location:
  • Phone: 610-583-3454
  • Fax:
Mailing address:
  • Phone: 610-583-3454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS038564
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS041461
License Number StatePA

VIII. Authorized Official

Name: DR. AAKASH C MUDALIAR
Title or Position: VICE PRESIDENT
Credential: DMD
Phone: 570-309-8223