Provider Demographics
NPI:1497896682
Name:AVALON DENTAL LLC
Entity Type:Organization
Organization Name:AVALON DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PARHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FARHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-998-9244
Mailing Address - Street 1:301 S OLD DUPONT RD
Mailing Address - Street 2:STE A
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804-0000
Mailing Address - Country:US
Mailing Address - Phone:302-998-9244
Mailing Address - Fax:
Practice Address - Street 1:301 S OLD DUPONT RD
Practice Address - Street 2:STE A
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19804-0000
Practice Address - Country:US
Practice Address - Phone:302-998-9244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-100012001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000040450Medicaid
DE1000038597Medicaid
DE1000040646Medicaid