MEDICARE: DEBRA V. IRVIN, DDS, PC

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	261QD0000X	Dental Clinic/Center	DS023289L	PA

General Provider Information

NPI Number	:	1588965537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEBRA V. IRVIN, DDS, PC

Provider Business Mailing Address
First Line	:	5201 N BROAD ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19141-1627
Country	:	US
Telephone Number	:	215-329-5512
Fax Number	:	215-329-0401

Provider Business Practice Location Address
First Line	:	5201 N BROAD ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19141-1627
Country	:	US
Telephone Number	:	215-329-5512
Fax Number	:	215-329-0401

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. DEBRA VIVIAN IRVIN
Credential	:	DDS
Telephone Number	:	215-329-5512

Provider Enumeration Date	:	11/08/2010
Last Update Date	:	11/08/2010

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