Provider Demographics
NPI:1871287466
Name:PADODARA, ROSHAN SANJAY (DMD)
Entity type:Individual
Prefix:DR
First Name:ROSHAN
Middle Name:SANJAY
Last Name:PADODARA
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 1:2863 LEE DR
Mailing Address - Street 2:
Mailing Address - City:JAMISON
Mailing Address - State:PA
Mailing Address - Zip Code:18929-1047
Mailing Address - Country:US
Mailing Address - Phone:215-858-2063
Mailing Address - Fax:
Practice Address - Street 1:1500 JOHN F KENNEDY BLVD STE 1906
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1714
Practice Address - Country:US
Practice Address - Phone:215-709-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0441001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice