Healthcare Provider Details

I. General information

NPI: 1841278033
Provider Name (Legal Business Name): LARRY P MOLDER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MONUMENT RD
PHILADELPHIA PA
19131-1616
US

IV. Provider business mailing address

113 FENWICK CT
CHERRY HILL NJ
08034-3312
US

V. Phone/Fax

Practice location:
  • Phone: 215-877-1925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS-024853-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: