Healthcare Provider Details

I. General information

NPI: 1417366881
Provider Name (Legal Business Name): JAMES CAVALANCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2014
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 N 5TH ST
INDIANA PA
15701-1983
US

IV. Provider business mailing address

2018 WALNUT ST
PHILADELPHIA PA
19103-5608
US

V. Phone/Fax

Practice location:
  • Phone: 724-388-6133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS039961
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS039961
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: