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General NPI Number Information
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NPI Number | 1376700336
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Entity Type | Individual
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Provider Name | OMID MEHDIPOUR DDS
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Gender | Male
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Dates
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Enumeration Date | 05/19/2008
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Last Update Date | 12/29/2015
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Provider Practice Location Address
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Address Line | 7900 OLD YORK RD #108A
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City | ELKINS PARK
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State | PA
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Zip | 19027-2318
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Country | US
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Telephone | 215-635-0808
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Fax |
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Provider Business Mailing Address
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Address Line | 901 NORTH PENN STREET R-2101
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City | PHILADELPHIA
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State | PA
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Zip | 19123
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Country | US
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Telephone | 202-758-9707
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DS039086
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License Number State | PA
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