Healthcare Provider Details

I. General information

NPI: 1346579968
Provider Name (Legal Business Name): THOMAS UPSITUR KING III D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W. ERIE AVE.
PHILA PA
19140-3544
US

IV. Provider business mailing address

1725 W. ERIE AVE.
PHILA PA
19140-3544
US

V. Phone/Fax

Practice location:
  • Phone: 215-226-1188
  • Fax: 215-226-6909
Mailing address:
  • Phone: 215-226-1188
  • Fax: 215-226-6909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS014278-L
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: