Healthcare Provider Details

I. General information

NPI: 1831642917
Provider Name (Legal Business Name): DENTISTRY AT 1818 MARKET ST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 MARKET ST SUITE 100
PHILADELPHIA PA
19103-3638
US

IV. Provider business mailing address

1818 MARKET ST SUITE 100
PHILADELPHIA PA
19103-3638
US

V. Phone/Fax

Practice location:
  • Phone: 215-567-2666
  • Fax:
Mailing address:
  • Phone: 215-567-2666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125K00000X
TaxonomyAdvanced Practice Dental Therapist
License NumberDS017950
License Number StatePA

VIII. Authorized Official

Name: MRS. ELAINE COADY
Title or Position: OFFICE MANAGER
Credential:
Phone: 215-567-2666