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General NPI Number Information
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NPI Number | 1508152919
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Entity Type | Organization
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Legal Business Name | ADVANCED DENTAL SERVICES, P.C
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Dates
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Enumeration Date | 06/23/2011
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Last Update Date | 06/23/2011
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Provider Practice Location Address
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Address Line | 11880 BUSTLETON AVE UNIT A
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City | PHILADELPHIA
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State | PA
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Zip | 19116-2538
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Country | US
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Telephone | 215-969-2015
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Fax |
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Provider Business Mailing Address
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Address Line | 11880 BUSTLETON AVE UNIT A
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City | PHILADELPHIA
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State | PA
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Zip | 19116-2538
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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/DENTIST
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Name | DMITRY KARAGODSKY
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Credential |
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Telephone | 215-696-2015
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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 | DS031011L
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License Number State | PA
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