Provider Demographics
NPI:1699073239
Name:NORTHEASTERN DENTISTRY @ OVERBROOK
Entity type:Organization
Organization Name:NORTHEASTERN DENTISTRY @ OVERBROOK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHADHALAVADA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-325-0560
Mailing Address - Street 1:6554 LEBANON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-3328
Mailing Address - Country:US
Mailing Address - Phone:215-878-0058
Mailing Address - Fax:877-707-5571
Practice Address - Street 1:6554 LEBANON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151-3328
Practice Address - Country:US
Practice Address - Phone:215-878-0058
Practice Address - Fax:877-707-5571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-07
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020256650007Medicaid