Provider Demographics
NPI:1558703157
Name:COMPLETE CARE FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:COMPLETE CARE FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ASHALATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANCHARLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:484-366-3775
Mailing Address - Street 1:6001 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19142-1410
Mailing Address - Country:US
Mailing Address - Phone:484-366-3775
Mailing Address - Fax:
Practice Address - Street 1:6001 CHESTER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-1410
Practice Address - Country:US
Practice Address - Phone:484-366-3775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty