Provider Demographics
NPI:1053970749
Name:PHILIP, NISHITA
Entity type:Individual
Prefix:
First Name:NISHITA
Middle Name:
Last Name:PHILIP
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 1:826 BUSTLETON PIKE STE 105
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-6002
Mailing Address - Country:US
Mailing Address - Phone:609-416-8767
Mailing Address - Fax:
Practice Address - Street 1:826 BUSTLETON PIKE STE 105
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6002
Practice Address - Country:US
Practice Address - Phone:609-416-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist