Provider Demographics
NPI:1770821761
Name:MONTGOMERY MALL DENTAL, LLP
Entity Type:Organization
Organization Name:MONTGOMERY MALL DENTAL, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIKTORIYA
Authorized Official - Middle Name:I
Authorized Official - Last Name:SHAAKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-362-5666
Mailing Address - Street 1:154 MONTGOMERY MALL
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-3909
Mailing Address - Country:US
Mailing Address - Phone:215-356-6666
Mailing Address - Fax:
Practice Address - Street 1:154 MONTGOMERY MALL
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-3909
Practice Address - Country:US
Practice Address - Phone:215-356-6666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA193200000XOtherMULTI-SPECIALTY GROUP