Healthcare Provider Details

I. General information

NPI: 1316728652
Provider Name (Legal Business Name): SPARK ORAL SURGERY PA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 LAUREL MALL
HAZLE TOWNSHIP PA
18202-1205
US

IV. Provider business mailing address

300 WILLOWBROOK LN STE 330
WEST CHESTER PA
19382-5594
US

V. Phone/Fax

Practice location:
  • Phone: 610-223-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: PHI LE
Title or Position: GENERAL COUNSEL
Credential:
Phone: 267-575-2321