Provider Demographics
NPI:1780134155
Name:MEMAR, MEENA (DMD)
Entity type:Individual
Prefix:
First Name:MEENA
Middle Name:
Last Name:MEMAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 N WOODBINE AVE
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1240
Mailing Address - Country:US
Mailing Address - Phone:601-664-3498
Mailing Address - Fax:
Practice Address - Street 1:240 S 40TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-6030
Practice Address - Country:US
Practice Address - Phone:601-664-3498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0408681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice