Provider Demographics
NPI:1679282743
Name:SPARK DENTAL IN, LLC
Entity Type:Organization
Organization Name:SPARK DENTAL IN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAER
Authorized Official - Prefix:
Authorized Official - First Name:PHI
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-575-2321
Mailing Address - Street 1:300 WILLOWBROOK LN STE 330
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-5594
Mailing Address - Country:US
Mailing Address - Phone:267-575-2321
Mailing Address - Fax:
Practice Address - Street 1:9602 E WASHINGTON ST STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3060
Practice Address - Country:US
Practice Address - Phone:317-898-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty