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General NPI Number Information
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NPI Number | 1417293739
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Entity Type | Organization
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Legal Business Name | IMPLANT DENTISTRY ASSOCIATES P.C.
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Dates
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Enumeration Date | 12/13/2012
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Last Update Date | 12/17/2012
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Provider Practice Location Address
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Address Line | 234 MALL BLVD SUITE 180
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City | KING OF PRUSSIA
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State | PA
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Zip | 19406-2954
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Country | US
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Telephone | 484-231-1177
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Fax | 484-231-8964
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Provider Business Mailing Address
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Address Line | 234 MALL BLVD SUITE 180
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City | KING OF PRUSSIA
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State | PA
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Zip | 19406-2954
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Country | US
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Telephone | 484-231-1177
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Fax | 484-231-8964
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Authorized Official
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Title or Position | MANAGER
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Name | MR. CLIFFORD GRATZ
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Credential |
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Telephone | 484-231-1177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | DS027440L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DS024390L
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DS035811L
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License Number State | PA
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