Provider Demographics
NPI:1477115889
Name:ISMAILOVA, SARDORA (DMD)
Entity Type:Individual
Prefix:
First Name:SARDORA
Middle Name:
Last Name:ISMAILOVA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 RED LION RD APT B2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-1406
Mailing Address - Country:US
Mailing Address - Phone:609-604-0000
Mailing Address - Fax:
Practice Address - Street 1:1625 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-4206
Practice Address - Country:US
Practice Address - Phone:215-336-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0423381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice