Provider Demographics
NPI:1124521646
Name:COLLINGDALE DENTAL ASSOCIATES
Entity type:Organization
Organization Name:COLLINGDALE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AAKASH
Authorized Official - Middle Name:C
Authorized Official - Last Name:MUDALIAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-309-8223
Mailing Address - Street 1:224 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19023-3712
Mailing Address - Country:US
Mailing Address - Phone:610-583-3454
Mailing Address - Fax:
Practice Address - Street 1:224 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:COLLINGDALE
Practice Address - State:PA
Practice Address - Zip Code:19023-3712
Practice Address - Country:US
Practice Address - Phone:610-583-3454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-11
Last Update Date:2018-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041461261QD0000X
PADS0385641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS041461OtherPENNSYLVANIA STATE BOARD OF DENTISTRY
PADS038564OtherPENNSYLVANIA STATE BOARD OF DENTISTRY