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General NPI Number Information
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NPI Number | 1093015406
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Entity Type | Organization
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Legal Business Name | COBBLESTONE KIDS PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 11/01/2010
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Last Update Date | 11/01/2010
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Provider Practice Location Address
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Address Line | 1352 SOUTH ST C5
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City | PHILADELPHIA
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State | PA
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Zip | 19147-1858
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Country | US
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Telephone | 215-913-3615
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Fax |
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Provider Business Mailing Address
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Address Line | 1101 WASHINGTON AVE VILLA 1
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City | PHILADELPHIA
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State | PA
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Zip | 19147-3839
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Country | US
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Telephone | 215-913-3615
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. GEORGE THOMAS LYNCH IV
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Credential | D.M.D.
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Telephone | 215-913-3615
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DS036787
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License Number State | PA
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