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General NPI Number Information
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NPI Number | 1568603744
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Entity Type | Organization
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Legal Business Name | OVERBROOK FARMS DENTAL GROUP
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Dates
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Enumeration Date | 03/17/2009
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Last Update Date | 03/17/2009
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Provider Practice Location Address
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Address Line | 2121 N 63RD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19151-2612
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Country | US
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Telephone | 215-878-0058
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Fax | 215-878-3834
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Provider Business Mailing Address
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Address Line | 2121 N 63RD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19151-2612
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Country | US
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Telephone | 215-878-0058
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Fax | 215-878-3834
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MARY ROSTAMI
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Credential | DMD
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Telephone | 215-878-0058
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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 | DS029137L
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License Number State | PA
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