Healthcare Provider Details

I. General information

NPI: 1811643703
Provider Name (Legal Business Name): SEPA DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 MILES RD UNIT 2
WEST CHESTER PA
19380-1950
US

IV. Provider business mailing address

1476 MUNDOCK RD
DRESHER PA
19025-1009
US

V. Phone/Fax

Practice location:
  • Phone: 609-792-3237
  • Fax:
Mailing address:
  • Phone: 609-792-3237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: RIINA ELSEY
Title or Position: OWNER
Credential: DMD
Phone: 609-792-3237