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General NPI Number Information
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NPI Number | 1942866280
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Entity Type | Individual
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Provider Name | TADELE DEMISSE DMD
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Gender | Male
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Dates
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Enumeration Date | 05/13/2019
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Last Update Date | 12/28/2023
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Provider Practice Location Address
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Address Line | 6120B WOODLAND AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19142-3224
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Country | US
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Telephone | 267-597-3600
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Fax |
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Provider Business Mailing Address
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Address Line | 4700 WISSAHICKON AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19144-4248
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Country | US
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Telephone | 267-597-3600
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 061697
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DS043969
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License Number State | PA
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