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General NPI Number Information
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NPI Number | 1902051535
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Entity Type | Organization
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Legal Business Name | GALLERY MALL DENTAL PC
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Dates
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Enumeration Date | 11/24/2008
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Last Update Date | 12/18/2009
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Provider Practice Location Address
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Address Line | 901 MARKET ST SPACE 3220 GALLERY MALL ONE
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City | PHILADELPHIA
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State | PA
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Zip | 19107
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Country | US
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Telephone | 215-627-4290
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Fax | 215-627-4293
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Provider Business Mailing Address
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Address Line | 901 MARKET ST SPACE 3220
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City | PHILADELPHIA
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State | PA
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Zip | 19107
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Country | US
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Telephone | 215-627-4290
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Fax | 215-627-4293
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Authorized Official
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Title or Position | PARTNER
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Name | PROLAY KUMAR PAUL
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Credential | D.D.S
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Telephone | 215-627-4290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS037088
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS037098
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License Number State | PA
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