Provider First Line Business Practice Location Address:
3223 N BROAD ST
Provider Second Line Business Practice Location Address:
TEMPLE UNIVERSITY SCHOOL OF DENTISTRY - ROOM 2E05
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19140-5007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-707-5934
Provider Business Practice Location Address Fax Number:
215-707-2840
Provider Enumeration Date:
05/21/2009