Healthcare Provider Details

I. General information

NPI: 1760465272
Provider Name (Legal Business Name): THOMAS C. BACKENSTOSE JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 N COLUMBUS BLVD APT 238
PHILADELPHIA PA
19106-1421
US

IV. Provider business mailing address

7 N COLUMBUS BLVD APT 238
PHILADELPHIA PA
19106-1421
US

V. Phone/Fax

Practice location:
  • Phone: 612-802-4697
  • Fax: 215-583-5222
Mailing address:
  • Phone: 612-802-4697
  • Fax: 215-583-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD10848
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: