MEDICARE: COMPLETE CARE FAMILY DENTISTRY, 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	122300000X	Dentist	DS038394	PA

General Provider Information

NPI Number	:	1558703157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPLETE CARE FAMILY DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	6001 CHESTER AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19142-1410
Country	:	US
Telephone Number	:	484-366-3775
Fax Number	:

Provider Business Practice Location Address
First Line	:	6001 CHESTER AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19142-1410
Country	:	US
Telephone Number	:	484-366-3775
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	ASHALATHA KANCHARLA
Credential	:	DDS
Telephone Number	:	484-366-3775

Provider Enumeration Date	:	07/24/2013
Last Update Date	:	07/24/2013

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