1114384799 NPI number — SPECIALTY DENTAL PARTNERS OF PHILADELPHIA PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114384799 NPI number — SPECIALTY DENTAL PARTNERS OF PHILADELPHIA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALTY DENTAL PARTNERS OF PHILADELPHIA PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114384799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
136 4TH ST N STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33701-3889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-800-8026
Provider Business Mailing Address Fax Number:
727-304-3164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 COMPUTER RD STE L62
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLOW GROVE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19090-1739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-618-8798
Provider Business Practice Location Address Fax Number:
215-383-0115
Provider Enumeration Date:
01/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LESSO
Authorized Official First Name:
ROSA
Authorized Official Middle Name:
Authorized Official Title or Position:
NATIONAL DIRECTOR OF RCM
Authorized Official Telephone Number:
714-571-3471

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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