Provider Demographics
NPI:1033622261
Name:FRANFORD AVE DENTAL GROUP LLC
Entity Type:Organization
Organization Name:FRANFORD AVE DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANTI
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDAMBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-876-3300
Mailing Address - Street 1:7538 FRANKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-3533
Mailing Address - Country:US
Mailing Address - Phone:215-333-4744
Mailing Address - Fax:
Practice Address - Street 1:7538 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-3533
Practice Address - Country:US
Practice Address - Phone:215-333-4744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038385261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS038385OtherSTATE LICENSE