MEDICARE: RUPAL TAILOR D.M.D.

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	DS041134	PA
2	1223G0001X	General Practice Dentistry	DS041134	PA

General Provider Information

NPI Number	:	1588196950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUPAL TAILOR D.M.D.

Provider Business Mailing Address
First Line	:	3032 RIDGEVIEW DRIVE
Second Line	:
City	:	ORWIGSBURG
State	:	PA
Zip	:	17961
Country	:	US
Telephone Number	:	570-573-5121
Fax Number	:

Provider Business Practice Location Address
First Line	:	2228 STATE HILL RD
Second Line	:
City	:	WYOMISSING
State	:	PA
Zip	:	19610-1904
Country	:	US
Telephone Number	:	610-816-6306
Fax Number	:

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

Provider Enumeration Date	:	04/03/2017
Last Update Date	:	04/03/2017

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