Healthcare Provider Details

I. General information

NPI: 1265939052
Provider Name (Legal Business Name): SHRADDHA BHISHAK KAMAT DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 02/28/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

IV. Provider business mailing address

1638 COPPER BEECH CIR
HUNTINGDON VALLEY PA
19006-7771
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-2900
  • Fax:
Mailing address:
  • Phone: 856-938-8671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number062877
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDS040682
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: