Provider Demographics
NPI:1841792066
Name:PROSPECT PARK COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:PROSPECT PARK COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHWETA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-532-5000
Mailing Address - Street 1:338 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:PROSPECT PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19076-2421
Mailing Address - Country:US
Mailing Address - Phone:610-532-5000
Mailing Address - Fax:610-461-1119
Practice Address - Street 1:338 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:PROSPECT PARK
Practice Address - State:PA
Practice Address - Zip Code:19076-2421
Practice Address - Country:US
Practice Address - Phone:610-532-4145
Practice Address - Fax:610-532-5000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-03
Last Update Date:2018-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037293261QD0000X
NJ22DI02362100261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental