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General NPI Number Information
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NPI Number | 1326417551
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Entity Type | Organization
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Legal Business Name | PIMD DENTAL
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Dates
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Enumeration Date | 09/17/2015
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Last Update Date | 09/17/2015
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Provider Practice Location Address
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Address Line | 7130 RISING SUN AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19111-3957
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Country | US
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Telephone | 786-319-2474
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Fax |
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Provider Business Mailing Address
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Address Line | 7130 RISING SUN AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19111-3957
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | MR. CHENET P. LAROSE
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Credential | DENTIST
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Telephone | 786-319-2474
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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 | DS027302L
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License Number State | PA
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