Healthcare Provider Details

I. General information

NPI: 1073091120
Provider Name (Legal Business Name): IVAN R MILORADOVIC DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

IV. Provider business mailing address

643 WASHINGTON LN
JENKINTOWN PA
19046-2333
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-2200
  • Fax:
Mailing address:
  • Phone: 610-547-3087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS041783
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: