Provider Demographics
NPI:1255619920
Name:ELITE DENTAL, LLC
Entity type:Organization
Organization Name:ELITE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR DOCTOR CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KURAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-274-4526
Mailing Address - Street 1:1575 N 52ND ST
Mailing Address - Street 2:SUITE 705
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-4736
Mailing Address - Country:US
Mailing Address - Phone:215-879-1777
Mailing Address - Fax:215-879-8077
Practice Address - Street 1:1575 N 52ND ST
Practice Address - Street 2:SUITE 705
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-4736
Practice Address - Country:US
Practice Address - Phone:215-879-1777
Practice Address - Fax:215-879-8077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty