Healthcare Provider Details

I. General information

NPI: 1700563939
Provider Name (Legal Business Name): SPARK ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2951 SAINT LAWRENCE AVE
READING PA
19606-2256
US

IV. Provider business mailing address

300 WILLOWBROOK LN STE 300
WEST CHESTER PA
19382-5594
US

V. Phone/Fax

Practice location:
  • Phone: 610-779-6990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: VAN PHI LE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 267-575-2321