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General NPI Number Information
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NPI Number | 1598034639
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Entity Type | Organization
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Legal Business Name | UNIVERSITY OF PENN-DENTAL MED ASST
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Dates
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Enumeration Date | 12/19/2011
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Last Update Date | 01/05/2012
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Provider Practice Location Address
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Address Line | 3400 CIVIC CENTER BLVD 1 EAST PAVILION
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City | PHILADELPHIA
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State | PA
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Zip | 19104-5127
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Country | US
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Telephone | 215-662-2450
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Fax |
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Provider Business Mailing Address
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Address Line | 3400 CIVIC CENTER BLVD 1 EAST PAVILION
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City | PHILADELPHIA
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State | PA
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Zip | 19104-5127
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Country | US
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Telephone | 215-662-2450
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Fax |
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Authorized Official
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Title or Position | MD
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Name | GARY W CROOKS
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Credential |
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Telephone | 215-662-2450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MD028425E
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License Number State | PA
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