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General NPI Number Information
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NPI Number | 1740328939
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Entity Type | Organization
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Legal Business Name | CHESTNUT DENTAL ARTS
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3 WEST GOWEN AVENUE
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City | PHILADELPHIA
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State | PA
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Zip | 19119
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Country | US
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Telephone | 215-242-0670
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Fax | 215-248-3874
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Provider Business Mailing Address
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Address Line | 3 WEST GOWEN AVENUE
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City | PHILADELPHIA
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State | PA
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Zip | 19119
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Country | US
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Telephone | 215-242-0670
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Fax | 215-248-3874
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Authorized Official
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Title or Position | DENTIST
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Name | DR. DERRICK BRANDON GRAVES
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Credential | D.M.D.
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Telephone | 215-242-0670
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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 | DS025356L
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License Number State | PA
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