Healthcare Provider Details

I. General information

NPI: 1528116738
Provider Name (Legal Business Name): ENDODONTIC SPECIALIST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 OLD EAGLE SCHOOL RD
WAYNE PA
19087-2544
US

IV. Provider business mailing address

85 OLD EAGLE SCHOOL RD
WAYNE PA
19087-2544
US

V. Phone/Fax

Practice location:
  • Phone: 610-995-0109
  • Fax: 610-995-0107
Mailing address:
  • Phone: 610-995-0109
  • Fax: 610-995-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS-025210L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierDS-025210L
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerDENTAL LICENSE

VIII. Authorized Official

Name: DR. BRUCE R TERRY
Title or Position: OWNER
Credential: D.M.D
Phone: 610-995-0109