Healthcare Provider Details

I. General information

NPI: 1902297823
Provider Name (Legal Business Name): DENTAL ARTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2015
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WALNUT ST SUITE 1217
PHILADELPHIA PA
19102-2944
US

IV. Provider business mailing address

2300 WALNUT ST SUITE 1217
PHILADELPHIA PA
19103-5552
US

V. Phone/Fax

Practice location:
  • Phone: 215-575-0550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS039657
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH071243
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS039480
License Number StatePA

VIII. Authorized Official

Name: DR. MARYAM ROSTAMI
Title or Position: PARTNER DENTIST
Credential: DMD
Phone: 215-575-0550