Provider Demographics
NPI:1720495195
Name:EVERGRIN LLC
Entity Type:Organization
Organization Name:EVERGRIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PRIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-981-2652
Mailing Address - Street 1:320 N OXFORD VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLESS HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19030-2610
Mailing Address - Country:US
Mailing Address - Phone:215-946-9400
Mailing Address - Fax:215-946-9409
Practice Address - Street 1:2416 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4418
Practice Address - Country:US
Practice Address - Phone:267-981-2652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0380951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty