Healthcare Provider Details

I. General information

NPI: 1023175080
Provider Name (Legal Business Name): EDWIN ROSENBERG B.D.S.H.DIP.DENT.DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LOCUST ST SUITE 1408
PHILADELPHIA PA
19102-4329
US

IV. Provider business mailing address

1500 LOCUST ST SUITE 1408
PHILADELPHIA PA
19102-4329
US

V. Phone/Fax

Practice location:
  • Phone: 215-732-4450
  • Fax: 215-722-3734
Mailing address:
  • Phone: 215-732-4450
  • Fax: 215-722-3734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number19706
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: