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General NPI Number Information
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NPI Number | 1619260155
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Entity Type | Organization
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Legal Business Name | CONSHOHOCKEN DENTAL GROUP, LLC
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Dates
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Enumeration Date | 05/17/2011
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Last Update Date | 05/17/2011
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Provider Practice Location Address
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Address Line | 200 W RIDGE PIKE SUITE #129
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City | CONSHOHOCKEN
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State | PA
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Zip | 19428-3702
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Country | US
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Telephone | 610-828-3535
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Fax | 610-828-3558
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Provider Business Mailing Address
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Address Line | 200 W RIDGE PIKE SUITE #129
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City | CONSHOHOCKEN
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State | PA
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Zip | 19428-3702
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Country | US
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Telephone | 610-828-3535
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Fax | 610-828-3558
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WANSUK SETH SEO
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Credential | DMD
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Telephone | 610-828-3535
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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 | DS038105
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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 | DS035484
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DS036612
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License Number State | PA
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