Provider Demographics
NPI:1902895196
Name:DOMADIA, PUSHPA N (DDS)
Entity Type:Individual
Prefix:DR
First Name:PUSHPA
Middle Name:N
Last Name:DOMADIA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-2207
Mailing Address - Country:US
Mailing Address - Phone:215-634-4647
Mailing Address - Fax:215-634-4647
Practice Address - Street 1:128 E ALLEGHENY AVE.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-2207
Practice Address - Country:US
Practice Address - Phone:215-634-4647
Practice Address - Fax:215-634-4647
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021004-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0990660Medicaid
PADO/460384OtherPENNSYLVANIA BLUE SHIELD