Healthcare Provider Details

I. General information

NPI: 1104096247
Provider Name (Legal Business Name): SHURONG CAO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5828 B MARKET STREET 2ND FLOOR
PHILADELPHIA PA
19139-3114
US

IV. Provider business mailing address

5828 B MARKET STREET 2ND FLOOR
PHILADELPHIA PA
19139-3114
US

V. Phone/Fax

Practice location:
  • Phone: 215-747-6901
  • Fax: 215-747-6907
Mailing address:
  • Phone: 215-747-6901
  • Fax: 215-747-6907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS035020
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS035020
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: