Provider Demographics
NPI:1457621559
Name:PAOLI FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:PAOLI FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SEPEHR
Authorized Official - Last Name:AGUBEGI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-647-0353
Mailing Address - Street 1:1410 RUSSELL ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301
Mailing Address - Country:US
Mailing Address - Phone:610-647-0353
Mailing Address - Fax:610-647-3946
Practice Address - Street 1:1410 RUSSELL ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301
Practice Address - Country:US
Practice Address - Phone:610-647-0353
Practice Address - Fax:610-647-3946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-030859-L1223G0001X
PADS020247L1223G0001X
PADS0374871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty