=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184152308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME CHOICE DENTAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2017
-----------------------------------------------------
Last Update Date | 06/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7155 OGONTZ AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-276-4532
-----------------------------------------------------
Fax | 215-276-4534
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7155 OGONTZ AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-276-4532
-----------------------------------------------------
Fax | 215-276-4534
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. NATASHA DAVTYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 267-736-9600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------