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General NPI Number Information
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NPI Number | 1811345275
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Entity Type | Organization
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Legal Business Name | INNOVATIVE DENTAL SERVICES, P.C.
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Dates
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Enumeration Date | 05/26/2016
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Last Update Date | 05/26/2016
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Provider Practice Location Address
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Address Line | 5737 N BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19141-2307
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Country | US
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Telephone | 215-275-6313
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Fax | 215-695-5511
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Provider Business Mailing Address
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Address Line | 1535 SWEETBRIAR DR
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City | JAMISON
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State | PA
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Zip | 18929-1653
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Country | US
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Telephone | 215-275-6313
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Fax | 215-695-5511
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Authorized Official
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Title or Position | OWNER
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Name | DR. OLGA KANDOV
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Credential | DMD
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Telephone | 215-275-6313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS037628
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License Number State | PA
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