=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053950444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTGOMERY EMERGENCY DENTIST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2020
-----------------------------------------------------
Last Update Date | 01/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 396 DOYLESTOWN RD
-----------------------------------------------------
City | MONTGOMERYVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18936-9609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-475-5140
-----------------------------------------------------
Fax | 215-475-5245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 396 DOYLESTOWN RD
-----------------------------------------------------
City | MONTGOMERYVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18936-9609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 121-547-5514
-----------------------------------------------------
Fax | 215-475-5245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | NICK SHARKOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-475-5140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------