Healthcare Provider Details

I. General information

NPI: 1336202787
Provider Name (Legal Business Name): BROOMALL PEDIATRIC DENTISTRY & ORTHODONTICS,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 W CHESTER PIKE
HAVERTOWN PA
19083-3339
US

IV. Provider business mailing address

1220 W CHESTER PIKE
HAVERTOWN PA
19083-3339
US

V. Phone/Fax

Practice location:
  • Phone: 484-454-3230
  • Fax: 484-455-7186
Mailing address:
  • Phone: 484-454-3230
  • Fax: 484-455-7186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StatePA

VIII. Authorized Official

Name: DR. JAY GOLDSLEGER
Title or Position: DENTIST,OWNER
Credential: D.D.S.
Phone: 484-454-3230