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General NPI Number Information
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NPI Number | 1013297779
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Entity Type | Organization
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Legal Business Name | AVENUE OF THE ARTS DENTAL
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Dates
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Enumeration Date | 08/25/2011
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Last Update Date | 08/25/2011
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Provider Practice Location Address
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Address Line | 622 S BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19146-1614
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Country | US
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Telephone | 215-545-0660
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Fax | 215-545-0665
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Provider Business Mailing Address
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Address Line | 622 S BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19146-1614
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Country | US
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Telephone | 215-545-0660
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Fax | 215-545-0665
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Authorized Official
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Title or Position | CEO
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Name | DR. MARK B HOANG
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Credential | DMD
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Telephone | 215-545-0660
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS037251
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License Number State | PA
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