Provider Demographics
NPI:1023887908
Name:PROSPECT PARK FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:PROSPECT PARK FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KETAV
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-583-5052
Mailing Address - Street 1:907 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:PROSPECT PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19076-1414
Mailing Address - Country:US
Mailing Address - Phone:610-583-5052
Mailing Address - Fax:
Practice Address - Street 1:907 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:PROSPECT PARK
Practice Address - State:PA
Practice Address - Zip Code:19076-1414
Practice Address - Country:US
Practice Address - Phone:610-583-5052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty