MEDICARE: MAIN LINE DENTAL GROUP PC

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	1223P0700X	Prosthodontics	DS022342L	PA

General Provider Information

NPI Number	:	1679618433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN LINE DENTAL GROUP PC

Provider Business Mailing Address
First Line	:	744 W LANCASTER AVE
Second Line	:	DEVON SQUARE II SUITE 115
City	:	WAYNE
State	:	PA
Zip	:	19087-2523
Country	:	US
Telephone Number	:	610-971-0717
Fax Number	:	610-971-9781

Provider Business Practice Location Address
First Line	:	744 WEST LANCASTER AVE
Second Line	:	DEVON SQUARE II SUITE 115
City	:	WAYNE
State	:	PA
Zip	:	19087-2523
Country	:	US
Telephone Number	:	610-971-0717
Fax Number	:	610-971-9781

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	DR. RONALD CRAIG WILLIAMS
Credential	:	DMD
Telephone Number	:	610-971-0717

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	07/19/2012

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Directions to “MAIN LINE DENTAL GROUP PC ” Practice Location

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