Provider Demographics
NPI:1255629531
Name:DIVINE DENTAL ARTS PC
Entity type:Organization
Organization Name:DIVINE DENTAL ARTS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:610-616-3641
Mailing Address - Street 1:40 BUCKWALTER RD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:ROYERSFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19468
Mailing Address - Country:US
Mailing Address - Phone:610-616-3641
Mailing Address - Fax:
Practice Address - Street 1:40 BUCKWALTER RD
Practice Address - Street 2:SUITE 309
Practice Address - City:ROYERSFORD
Practice Address - State:PA
Practice Address - Zip Code:19468
Practice Address - Country:US
Practice Address - Phone:610-616-3641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty