Healthcare Provider Details

I. General information

NPI: 1992958219
Provider Name (Legal Business Name): RIYA MAHESH KUKLANI B.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANITA RAMCHANDANI

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-3449
  • Fax: 215-707-2781
Mailing address:
  • Phone: 215-707-3449
  • Fax: 215-707-2781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDRP 548
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDS039414
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: