MEDICARE: DR. EVEROD A COLEMAN JR. DMD

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	DS018716L	PA

General Provider Information

NPI Number	:	1063787661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVEROD A COLEMAN JR. DMD

Provider Business Mailing Address
First Line	:	1601 WALNUT ST STE 720
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-2904
Country	:	US
Telephone Number	:	215-981-0380
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 WALNUT ST STE 720
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-2904
Country	:	US
Telephone Number	:	215-981-0380
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2012
Last Update Date	:	03/14/2012

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