Provider Demographics
NPI:1760558894
Name:INDIAN VALLEY DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:INDIAN VALLEY DENTAL ASSOCIATES
Other - Org Name:INDIAN VALLEY DENTAL ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:JARED
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-704-4546
Mailing Address - Street 1:601 E BROAD ST
Mailing Address - Street 2:SUITE #200
Mailing Address - City:SOUDERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18964-1263
Mailing Address - Country:US
Mailing Address - Phone:215-723-5531
Mailing Address - Fax:215-721-9119
Practice Address - Street 1:601 E BROAD ST
Practice Address - Street 2:SUITE #200
Practice Address - City:SOUDERTON
Practice Address - State:PA
Practice Address - Zip Code:18964-1263
Practice Address - Country:US
Practice Address - Phone:215-723-5531
Practice Address - Fax:215-721-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021793L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty