Healthcare Provider Details

I. General information

NPI: 1639558950
Provider Name (Legal Business Name): PEDIATRIC DENTAL ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E ALLEGHENY AVE SUITE 201
PHILADELPHIA PA
19134-4427
US

IV. Provider business mailing address

2301 E ALLEGHENY AVE SUITE 201
PHILADELPHIA PA
19134-4427
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-1030
  • Fax: 215-707-0083
Mailing address:
  • Phone: 215-707-1030
  • Fax: 215-707-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS036846
License Number StatePA

VIII. Authorized Official

Name: DR. MARK S GOLDSTEIN
Title or Position: PRESIDENT
Credential: DDS
Phone: 215-707-1016