Provider Demographics
NPI:1154548857
Name:PROVIDENCE ENDODONTICS LLC
Entity type:Organization
Organization Name:PROVIDENCE ENDODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEETU
Authorized Official - Middle Name:RALLI
Authorized Official - Last Name:KOHLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-676-9030
Mailing Address - Street 1:450 CRESSON BLVD,
Mailing Address - Street 2:SUITE 303, P.O.BOX 1218
Mailing Address - City:OAKS
Mailing Address - State:PA
Mailing Address - Zip Code:19456-1218
Mailing Address - Country:US
Mailing Address - Phone:610-676-9030
Mailing Address - Fax:610-676-9032
Practice Address - Street 1:450 CRESSON BLVD,
Practice Address - Street 2:SUITE 303
Practice Address - City:OAKS
Practice Address - State:PA
Practice Address - Zip Code:19456-1218
Practice Address - Country:US
Practice Address - Phone:610-676-9030
Practice Address - Fax:610-676-9032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty