Healthcare Provider Details

I. General information

NPI: 1114384799
Provider Name (Legal Business Name): SPECIALTY DENTAL PARTNERS OF PHILADELPHIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 COMPUTER RD STE L62
WILLOW GROVE PA
19090-1739
US

IV. Provider business mailing address

136 4TH ST N STE 201
ST PETERSBURG FL
33701-3889
US

V. Phone/Fax

Practice location:
  • Phone: 215-618-8798
  • Fax: 215-383-0115
Mailing address:
  • Phone: 727-800-8026
  • Fax: 727-304-3164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ROSA LESSO
Title or Position: NATIONAL DIRECTOR OF RCM
Credential:
Phone: 714-571-3471