Provider Demographics
NPI:1275272528
Name:BANSAL, SUCHETA
Entity Type:Individual
Prefix:DR
First Name:SUCHETA
Middle Name:
Last Name:BANSAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 W ALLEGHENY AVE APT 502
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-1711
Mailing Address - Country:US
Mailing Address - Phone:215-444-3624
Mailing Address - Fax:
Practice Address - Street 1:400 W ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3614
Practice Address - Country:US
Practice Address - Phone:215-291-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0436701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice