Healthcare Provider Details

I. General information

NPI: 1861645145
Provider Name (Legal Business Name): PENN PREMIER DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 EXTON SQUARE MALL
EXTON PA
19341-2440
US

IV. Provider business mailing address

194 EXTON SQUARE MALL
EXTON PA
19341-2440
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-5810
  • Fax: 610-594-0667
Mailing address:
  • Phone: 610-363-5810
  • Fax: 610-594-0667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS037327
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS037059
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS036832
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS037059
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS023283Y
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS036138
License Number StatePA
# 7
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS036830
License Number StatePA
# 8
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS036955
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. SHAHRAM SHAMLOO
Title or Position: VICE PRESIDENT
Credential: DMD
Phone: 610-363-5810