MEDICARE: SERGEY DEDOV DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS039639	PA

General Provider Information

NPI Number	:	1043651334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERGEY DEDOV DDS

Provider Business Mailing Address
First Line	:	643 COLEBROOK RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-2808
Country	:	US
Telephone Number	:	267-632-1852
Fax Number	:

Provider Business Practice Location Address
First Line	:	643 COLEBROOK RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-2808
Country	:	US
Telephone Number	:	267-632-1852
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2013
Last Update Date	:	07/15/2013

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