Healthcare Provider Details

I. General information

NPI: 1932556925
Provider Name (Legal Business Name): ARDMORE PEDIATRIC DENTAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 E LANCASTER AVE SUITE 201
ARDMORE PA
19003-2321
US

IV. Provider business mailing address

596 LANCASTER AVE SUITE 101
MALVERN PA
19355-1808
US

V. Phone/Fax

Practice location:
  • Phone: 610-896-8300
  • Fax:
Mailing address:
  • Phone: 484-679-4071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS020687L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS018777L
License Number StatePA

VIII. Authorized Official

Name: JAY GOLDSLEGER
Title or Position: PRESIDENT
Credential: DMD
Phone: 610-896-8300