Healthcare Provider Details

I. General information

NPI: 1063536290
Provider Name (Legal Business Name): LOCUST STREET PERIODONTICS IMPLANT DENTISTRY L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LOCUST ST. SUITE 1408
PHILADELPHIA PA
19102-4314
US

IV. Provider business mailing address

1500 LOCUST ST. SUITE 1408
PHILADELPHIA PA
19102-4314
US

V. Phone/Fax

Practice location:
  • Phone: 215-732-4450
  • Fax: 215-735-9886
Mailing address:
  • Phone: 215-732-4450
  • Fax: 215-735-9886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS018466L
License Number StatePA

VIII. Authorized Official

Name: DR. JOSEPH GIAN-GRASSO
Title or Position: OWNER
Credential: D.M.D.
Phone: 215-732-4450