Healthcare Provider Details

I. General information

NPI: 1578994521
Provider Name (Legal Business Name): QUAKERTOWN PERIO-IMPLANT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 W BROAD ST
QUAKERTOWN PA
18951-1110
US

IV. Provider business mailing address

1402 W BROAD ST
QUAKERTOWN PA
18951-1110
US

V. Phone/Fax

Practice location:
  • Phone: 215-536-7705
  • Fax: 215-536-7740
Mailing address:
  • Phone: 215-536-7705
  • Fax: 215-536-7740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DONNA LEE ENDY
Title or Position: PRESIDENT
Credential: DMD
Phone: 215-536-7705