MEDICARE: PENNSYLVANIA DENTAL GROUP LTD.

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	DS18682L	PA

General Provider Information

NPI Number	:	1114054962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENNSYLVANIA DENTAL GROUP LTD.

Provider Business Mailing Address
First Line	:	3550 MARKET ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3329
Country	:	US
Telephone Number	:	215-387-0883
Fax Number	:	215-387-9659

Provider Business Practice Location Address
First Line	:	3550 MARKET ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3329
Country	:	US
Telephone Number	:	215-387-0883
Fax Number	:	215-387-9659

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GEORGE E. BOUDREAU
Credential	:
Telephone Number	:	215-387-0883

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	08/22/2020

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