MEDICARE: 5TH STREET DENTAL

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1598044471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5TH STREET DENTAL

Provider Business Mailing Address
First Line	:	2822 N 5TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-2712
Country	:	US
Telephone Number	:	215-333-6825
Fax Number	:	215-335-4340

Provider Business Practice Location Address
First Line	:	2822 N 5TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-2712
Country	:	US
Telephone Number	:	215-333-6825
Fax Number	:	215-335-4340

Authorized Official
Title or Position	:	OWNER
Name	:	MS. P TRIVEDI
Credential	:
Telephone Number	:	215-333-6825

Provider Enumeration Date	:	08/10/2011
Last Update Date	:	08/10/2011

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Directions to “5TH STREET DENTAL ” Practice Location

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