=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568690931
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEELA THIRUGNANAM DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2009
-----------------------------------------------------
Last Update Date | 06/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2137 WELSH RD STE 3C
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19115-4963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-464-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 TRAPPE LN
-----------------------------------------------------
City | LANGHORNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19047-1434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-850-4514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS037750
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------