MEDICARE: COBBLESTONE KIDS PEDIATRIC DENTISTRY

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	1223P0221X	Pediatric Dentistry	DS036787	PA

General Provider Information

NPI Number	:	1093015406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COBBLESTONE KIDS PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	1101 WASHINGTON AVE
Second Line	:	VILLA 1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-3839
Country	:	US
Telephone Number	:	215-913-3615
Fax Number	:

Provider Business Practice Location Address
First Line	:	1352 SOUTH ST
Second Line	:	C5
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-1858
Country	:	US
Telephone Number	:	215-913-3615
Fax Number	:

Authorized Official
Title or Position	:	PEDIATRIC DENTIST
Name	:	DR. GEORGE THOMAS LYNCH IV
Credential	:	D.M.D.
Telephone Number	:	215-913-3615

Provider Enumeration Date	:	11/01/2010
Last Update Date	:	11/01/2010

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