Provider Demographics
NPI:1902051535
Name:GALLERY MALL DENTAL PC
Entity Type:Organization
Organization Name:GALLERY MALL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PROLAY
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:215-627-4290
Mailing Address - Street 1:901 MARKET ST
Mailing Address - Street 2:SPACE 3220
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-627-4290
Mailing Address - Fax:215-627-4293
Practice Address - Street 1:901 MARKET ST
Practice Address - Street 2:SPACE 3220 GALLERY MALL ONE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-627-4290
Practice Address - Fax:215-627-4293
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GALLERY MALL DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-24
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037098122300000X
PADS037088122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========Medicaid