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General NPI Number Information
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NPI Number | 1336673417
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Entity Type | Organization
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Legal Business Name | BALA KIDS DENTISTRY
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Dates
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Enumeration Date | 04/17/2017
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Last Update Date | 04/17/2017
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Provider Practice Location Address
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Address Line | 15 N PRESIDENTIAL BLVD SUITE 303
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City | BALA CYNWYD
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State | PA
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Zip | 19004-1006
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Country | US
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Telephone | 610-336-8478
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Fax | 610-617-9275
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Provider Business Mailing Address
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Address Line | 15 N PRESIDENTIAL BLVD SUITE 303
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City | BALA CYNWYD
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State | PA
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Zip | 19004-1006
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Country | US
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Telephone | 610-336-8478
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Fax | 610-617-9275
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LISA WAXMAN
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Credential |
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Telephone | 610-667-6161
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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 | DS040852
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License Number State | PA
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