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General NPI Number Information
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NPI Number | 1417465402
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Entity Type | Organization
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Legal Business Name | DENTAL WIZARD G PC
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Dates
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Enumeration Date | 01/12/2018
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 2338 N FRONT ST
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City | PHILADELPHIA
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State | PA
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Zip | 19133-3716
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Country | US
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Telephone | 267-886-9474
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Fax |
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Provider Business Mailing Address
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Address Line | 2338 N FRONT ST
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City | PHILADELPHIA
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State | PA
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Zip | 19133-3716
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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 | OWNER
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Name | OLEG GENIS
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Credential | DMD
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Telephone | 267-886-9474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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