Provider Demographics
NPI:1356531545
Name:FAIRMONT DENTAL ASSOCIATES PC
Entity type:Organization
Organization Name:FAIRMONT DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:N
Authorized Official - Last Name:KALOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-435-1288
Mailing Address - Street 1:1414 W FAIRMONT ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18102-1021
Mailing Address - Country:US
Mailing Address - Phone:610-435-1288
Mailing Address - Fax:610-435-5451
Practice Address - Street 1:1414 W FAIRMONT ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102-1021
Practice Address - Country:US
Practice Address - Phone:610-435-1288
Practice Address - Fax:610-435-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS012453L122300000X
PADS016583L122300000X
PADS037274122300000X
PADS020234A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty