=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235346883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF PENN CHOP DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34TH STREET AND CIVIC CENTER BOULEVARD 2 MAIN
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-590-1563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34TH STREET AND CIVIC CENTER BOULEVARD 2 MAIN
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR PATIENT REVENUE
-----------------------------------------------------
Name | JOSEPH WOLK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-898-3576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DS020010L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------