Provider Demographics
NPI:1871292128
Name:FNU, KUSHALDEEP
Entity type:Individual
Prefix:
First Name:KUSHALDEEP
Middle Name:
Last Name:FNU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 N BROAD ST,
Mailing Address - Street 2:ROOM 2A05 (SECOND FLOOR)
Mailing Address - City:PHILADELPHIA,
Mailing Address - State:PA
Mailing Address - Zip Code:19140-1675
Mailing Address - Country:US
Mailing Address - Phone:215-707-7747
Mailing Address - Fax:
Practice Address - Street 1:3223 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF118311223P0700X
PARFD0000681223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics