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General NPI Number Information
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NPI Number | 1639370661
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Entity Type | Organization
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Legal Business Name | MAIN STREET DENTAL CENTER CITY PC
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Dates
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Enumeration Date | 05/29/2007
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Last Update Date | 04/22/2011
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Provider Practice Location Address
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Address Line | 1048 SOUTH ST
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City | PHILADELPHIA
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State | PA
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Zip | 19147-1935
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Country | US
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Telephone | 215-627-1995
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Fax | 215-627-1999
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Provider Business Mailing Address
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Address Line | 1048 SOUTH ST
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City | PHILADELPHIA
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State | PA
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Zip | 19147-1935
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Country | US
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Telephone | 215-627-1995
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Fax | 215-627-1999
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Authorized Official
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Title or Position | PRESIDENT DENTIST
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Name | DR. RICHARD VICTOR EIDELSON
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Credential | DDS, FAGD
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Telephone | 215-627-1995
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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 | DS019673L
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License Number State | PA
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