Provider Demographics
NPI:1265459036
Name:VAIDYA, KANCHAN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:KANCHAN
Middle Name:C
Last Name:VAIDYA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-5346
Mailing Address - Country:US
Mailing Address - Phone:215-727-1010
Mailing Address - Fax:215-727-9396
Practice Address - Street 1:5635 CHESTER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-5346
Practice Address - Country:US
Practice Address - Phone:215-727-1010
Practice Address - Fax:215-727-9396
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO20414-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005294450001Medicaid
PA3909OtherUNITED CONCORDIA CO.