MEDICARE: PHILADELPHIA SMILE CETER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1396585212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILADELPHIA SMILE CETER LLC

Provider Business Mailing Address
First Line	:	1501 OLD YORK RD
Second Line	:
City	:	ABINGTON
State	:	PA
Zip	:	19001-1907
Country	:	US
Telephone Number	:	215-558-4205
Fax Number	:	215-494-3603

Provider Business Practice Location Address
First Line	:	11911 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-2541
Country	:	US
Telephone Number	:	215-673-9050
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. KIRIL SHARKOV
Credential	:
Telephone Number	:	215-391-5939

Provider Enumeration Date	:	05/29/2024
Last Update Date	:	05/29/2024

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