MEDICARE: OVERBROOK FARMS DENTAL GROUP

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	DS029137L	PA

General Provider Information

NPI Number	:	1568603744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OVERBROOK FARMS DENTAL GROUP

Provider Business Mailing Address
First Line	:	2121 N 63RD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19151-2612
Country	:	US
Telephone Number	:	215-878-0058
Fax Number	:	215-878-3834

Provider Business Practice Location Address
First Line	:	2121 N 63RD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19151-2612
Country	:	US
Telephone Number	:	215-878-0058
Fax Number	:	215-878-3834

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MARY ROSTAMI
Credential	:	DMD
Telephone Number	:	215-878-0058

Provider Enumeration Date	:	03/17/2009
Last Update Date	:	03/17/2009

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