MEDICARE: CHESTNUT HILL DENTAL, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS021970L	PA

General Provider Information

NPI Number	:	1063716611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHESTNUT HILL DENTAL, INC.

Provider Business Mailing Address
First Line	:	2 E CHESTNUT HILL AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-2715
Country	:	US
Telephone Number	:	215-242-6404
Fax Number	:	215-242-4907

Provider Business Practice Location Address
First Line	:	2 E CHESTNUT HILL AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-2715
Country	:	US
Telephone Number	:	215-242-6404
Fax Number	:	215-242-4907

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROBIN F. GALLAGHER
Credential	:	D.M.D
Telephone Number	:	215-242-6404

Provider Enumeration Date	:	12/22/2010
Last Update Date	:	12/22/2010

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