Healthcare Provider Details

I. General information

NPI: 1750441408
Provider Name (Legal Business Name): PHILIP A SHORE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TREATY RD
DREXEL HILL PA
19026-5023
US

IV. Provider business mailing address

200 TREATY RD
DREXEL HILL PA
19026-5023
US

V. Phone/Fax

Practice location:
  • Phone: 610-449-2424
  • Fax:
Mailing address:
  • Phone: 610-449-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS019091L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier159499
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerUNITED CONCORDIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: