Provider Demographics
NPI:1417366881
Name:CAVALANCIA, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:CAVALANCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:152 N 5TH ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-1983
Practice Address - Country:US
Practice Address - Phone:724-388-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0399611223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty