Healthcare Provider Details

I. General information

NPI: 1245284991
Provider Name (Legal Business Name): AUDUBON DENTAL ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2642 AUDUBON ROAD
AUDUBON PA
19403
US

IV. Provider business mailing address

2642 AUDUBON ROAD
AUDUBON PA
19403
US

V. Phone/Fax

Practice location:
  • Phone: 610-666-7590
  • Fax: 610-666-9565
Mailing address:
  • Phone: 610-666-7590
  • Fax: 610-666-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS017422L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS017084L
License Number StatePA

VIII. Authorized Official

Name: GEORGE W HECKERT JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 610-666-7590