1033424155 NPI number — DOMENIC BAGLIVO JR D.M.D., P.C

Table of content: (NPI 1033424155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033424155 NPI number — DOMENIC BAGLIVO JR D.M.D., P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOMENIC BAGLIVO JR D.M.D., P.C
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:
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:
1033424155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 EAST LANCASTER AVENUE
Provider Second Line Business Mailing Address:
LANKENAU MEDICAL BLDG - SUITE 203W
Provider Business Mailing Address City Name:
WYNNEWOOD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-642-0259
Provider Business Mailing Address Fax Number:
610-896-6405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E LANCASTER AVE. SUITE 203W
Provider Second Line Business Practice Location Address:
LANKENAU MEDICAL BUILDING SOUTH
Provider Business Practice Location Address City Name:
WYNNEWOOD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-642-0259
Provider Business Practice Location Address Fax Number:
610-896-6405
Provider Enumeration Date:
08/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BAGLIVO
Authorized Official First Name:
DOMENIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-642-0259

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DS-025340-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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