MEDICARE: EAGLE CREST 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

General Provider Information

NPI Number	:	1326392846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE CREST PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	31 S EAGLE RD
Second Line	:	SUITE 100
City	:	HAVERTOWN
State	:	PA
Zip	:	19083-3340
Country	:	US
Telephone Number	:	484-454-3568
Fax Number	:	484-454-3582

Provider Business Practice Location Address
First Line	:	31 S EAGLE RD
Second Line	:	SUITE 100
City	:	HAVERTOWN
State	:	PA
Zip	:	19083-3340
Country	:	US
Telephone Number	:	484-454-3568
Fax Number	:	484-454-3582

Authorized Official
Title or Position	:	OWNER / PEDIATRIC DENTIST
Name	:	ROSE WADENYA
Credential	:	DMD
Telephone Number	:	484-454-3568

Provider Enumeration Date	:	11/06/2012
Last Update Date	:	10/03/2014

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Directions to “EAGLE CREST PEDIATRIC DENTISTRY ” Practice Location

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