Provider Demographics
NPI:1346886884
Name:SPA DENTAL GROUP INC.
Entity Type:Organization
Organization Name:SPA DENTAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHEBANI
Authorized Official - Middle Name:
Authorized Official - Last Name:PAHWA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-910-3100
Mailing Address - Street 1:111 E 57TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2009
Mailing Address - Country:US
Mailing Address - Phone:917-858-7155
Mailing Address - Fax:732-631-8525
Practice Address - Street 1:111 E 57TH ST # 204
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2009
Practice Address - Country:US
Practice Address - Phone:202-431-6957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPA DENTAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-19
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental