=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598244881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARAL I SEROON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2018
-----------------------------------------------------
Last Update Date | 08/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 W MARSHALL ST
-----------------------------------------------------
City | NORRISTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19401-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-704-7675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 W MARSHALL ST
-----------------------------------------------------
City | NORRISTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19401-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-704-7675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | MARAL SEROON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 610-348-1928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS039694
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------