MEDICARE: LOCUST STREET PERIODONTICS IMPLANT DENTISTRY L.L.C.

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	1223P0300X	Periodontics	DS018466L	PA

General Provider Information

NPI Number	:	1063536290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOCUST STREET PERIODONTICS IMPLANT DENTISTRY L.L.C.

Provider Business Mailing Address
First Line	:	1500 LOCUST ST.
Second Line	:	SUITE 1408
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-4314
Country	:	US
Telephone Number	:	215-732-4450
Fax Number	:	215-735-9886

Provider Business Practice Location Address
First Line	:	1500 LOCUST ST.
Second Line	:	SUITE 1408
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-4314
Country	:	US
Telephone Number	:	215-732-4450
Fax Number	:	215-735-9886

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOSEPH GIAN-GRASSO
Credential	:	D.M.D.
Telephone Number	:	215-732-4450

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	08/22/2020

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