=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255506887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLYMOUTH PERIODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2008
-----------------------------------------------------
Last Update Date | 04/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W GERMANTOWN PIKE SUITE 225
-----------------------------------------------------
City | PLYMOUTH MEETING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19462-1420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-825-4334
-----------------------------------------------------
Fax | 610-825-4747
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 W GERMANTOWN PIKE SUITE 225
-----------------------------------------------------
City | PLYMOUTH MEETING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19462-1420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-825-4334
-----------------------------------------------------
Fax | 610-825-4747
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/PERIODONTIST
-----------------------------------------------------
Name | DR. WENDY HALPERN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 610-825-4334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DS035306
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------