MEDICARE: CENTER CITY PERIODONTISTS, P.C.

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	1223P0300X	Periodontics	DS-016719-L	PA

General Provider Information

NPI Number	:	1164517140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER CITY PERIODONTISTS, P.C.

Provider Business Mailing Address
First Line	:	1500 LOCUST ST
Second Line	:	SUITE 1413
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-4329
Country	:	US
Telephone Number	:	215-546-3700
Fax Number	:	215-546-0393

Provider Business Practice Location Address
First Line	:	1500 LOCUST ST
Second Line	:	SUITE 1413
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-4329
Country	:	US
Telephone Number	:	215-546-3700
Fax Number	:	215-546-0393

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CAROLE N. HILDEBRAND
Credential	:	DDS, ME.D
Telephone Number	:	215-546-3700

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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