Healthcare Provider Details

I. General information

NPI: 1801925078
Provider Name (Legal Business Name): DPMKENTNERPRPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 WELSH RD
PHILADELPHIA PA
19115-4659
US

IV. Provider business mailing address

11773 DIMARCO DR
PHILADELPHIA PA
19154-3716
US

V. Phone/Fax

Practice location:
  • Phone: 215-677-3222
  • Fax: 215-677-3241
Mailing address:
  • Phone: 215-696-3674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberSC004823L
License Number StatePA

VIII. Authorized Official

Name: BRYAN KENTNER
Title or Position: OWNER
Credential: DPM
Phone: 215-696-3674