1114384799 NPI number — SPECIALTY DENTAL PARTNERS OF PHILADELPHIA PLLC

Table of content: (NPI 1114384799)

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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