Healthcare Provider Details

I. General information

NPI: 1134642382
Provider Name (Legal Business Name): ORTHODONTIC SPECIALISTS OF THE INDIAN VALLEY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 ROUTE 113
SOUDERTON PA
18964-1004
US

IV. Provider business mailing address

726 ROUTE 113
SOUDERTON PA
18964-1004
US

V. Phone/Fax

Practice location:
  • Phone: 267-225-8932
  • Fax:
Mailing address:
  • Phone: 267-225-8932
  • 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: JUSTIN SILVESTRE
Title or Position: OWNER
Credential: DMD
Phone: 267-225-8932