Provider Demographics
NPI:1780060871
Name:MOMOT, DARIYA
Entity type:Individual
Prefix:
First Name:DARIYA
Middle Name:
Last Name:MOMOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 SPRING GARDEN ST
Mailing Address - Street 2:SUITE 412
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3940
Mailing Address - Country:US
Mailing Address - Phone:917-868-4541
Mailing Address - Fax:
Practice Address - Street 1:301 S MAIN RD
Practice Address - Street 2:B4
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-7897
Practice Address - Country:US
Practice Address - Phone:856-691-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026102001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice