Provider Demographics
NPI:1962241216
Name:PROFKA, ENRI (DMD)
Entity type:Individual
Prefix:
First Name:ENRI
Middle Name:
Last Name:PROFKA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3339 OAKMONT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-3510
Mailing Address - Country:US
Mailing Address - Phone:267-361-9930
Mailing Address - Fax:
Practice Address - Street 1:701 E CATHEDRAL RD STE 43
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2128
Practice Address - Country:US
Practice Address - Phone:267-748-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0446231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice