Healthcare Provider Details

I. General information

NPI: 1629166020
Provider Name (Legal Business Name): SOCIETY HILL DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 S 5TH ST SUITE 610
PHILADELPHIA PA
19106-2515
US

IV. Provider business mailing address

21 S 5TH ST SUITE 610
PHILADELPHIA PA
19106-2515
US

V. Phone/Fax

Practice location:
  • Phone: 215-238-0800
  • Fax:
Mailing address:
  • Phone: 215-238-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS025793-L
License Number StatePA

VIII. Authorized Official

Name: DR. SCOTT J BONOMO
Title or Position: OWNER/VICE PRESIDENT
Credential: DMD
Phone: 215-238-0800