Healthcare Provider Details

I. General information

NPI: 1518912831
Provider Name (Legal Business Name): PEDIATRIC DENTAL ASSOCIATES OF WEST CHESTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9215 CINCINNATI COLUMBUS RD
WEST CHESTER OH
45069-4143
US

IV. Provider business mailing address

9215 CINCINNATI COLUMBUS RD
WEST CHESTER OH
45069-4143
US

V. Phone/Fax

Practice location:
  • Phone: 513-777-2313
  • Fax: 513-779-5942
Mailing address:
  • Phone: 513-777-2313
  • Fax: 513-779-5942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30014442
License Number StateOH

VIII. Authorized Official

Name: ERIC JOHN KOREN
Title or Position: OFFICER
Credential: DDS
Phone: 513-777-2313