Healthcare Provider Details

I. General information

NPI: 1568563070
Provider Name (Legal Business Name): ALLEN FRED FIELDING D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E LEHIGH AVE PM2
PHILADELPHIA PA
19125-1011
US

IV. Provider business mailing address

101 E LEHIGH AVE PM2
PHILADELPHIA PA
19125-1011
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-3613
  • Fax: 215-707-5405
Mailing address:
  • Phone: 215-707-3613
  • Fax: 215-707-5405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS016909L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: