Healthcare Provider Details

I. General information

NPI: 1154548857
Provider Name (Legal Business Name): PROVIDENCE ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 CRESSON BLVD, SUITE 303
OAKS PA
19456-1218
US

IV. Provider business mailing address

450 CRESSON BLVD, SUITE 303, P.O.BOX 1218
OAKS PA
19456-1218
US

V. Phone/Fax

Practice location:
  • Phone: 610-676-9030
  • Fax: 610-676-9032
Mailing address:
  • Phone: 610-676-9030
  • Fax: 610-676-9032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StatePA

VIII. Authorized Official

Name: DR. MEETU RALLI KOHLI
Title or Position: PARTNER
Credential: D.M.D
Phone: 610-676-9030