=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801126677
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHELDENTAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2009
-----------------------------------------------------
Last Update Date | 12/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1376 NAAMANS CREEK RD
-----------------------------------------------------
City | GARNET VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19060-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-459-5859
-----------------------------------------------------
Fax | 610-485-1782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1376 NAAMANS CREEK RD
-----------------------------------------------------
City | GARNET VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19060-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-459-5859
-----------------------------------------------------
Fax | 610-485-1782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | CHARLES J ROSE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 856-904-9946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI014622
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------