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General NPI Number Information
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NPI Number | 1932323235
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Entity Type | Organization
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Legal Business Name | RICHARD C SQUILLARO D.D.S., PC
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 05/14/2013
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Provider Practice Location Address
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Address Line | 2546 S BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19145-4638
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Country | US
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Telephone | 215-463-6677
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Fax | 215-463-1077
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Provider Business Mailing Address
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Address Line | 1512 TEMPLE DR
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City | MAPLE GLEN
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State | PA
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Zip | 19002-3312
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Country | US
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Telephone | 215-628-8627
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Fax | 215-628-8937
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICHARD CARMEN SQUILLARO
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Credential | D.D.S.
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Telephone | 215-463-6677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DS017459L
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License Number State | PA
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