=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720495195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGRIN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2014
-----------------------------------------------------
Last Update Date | 07/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2416 S BROAD ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19145-4418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-981-2652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 N OXFORD VALLEY RD
-----------------------------------------------------
City | FAIRLESS HILLS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19030-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-946-9400
-----------------------------------------------------
Fax | 215-946-9409
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/DIRECTOR
-----------------------------------------------------
Name | MS. PRIYA TRIVEDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 267-981-2652
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS038095
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------