Provider Demographics
NPI:1033424155
Name:DOMENIC BAGLIVO JR D.M.D., P.C
Entity Type:Organization
Organization Name:DOMENIC BAGLIVO JR D.M.D., P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGLIVO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-642-0259
Mailing Address - Street 1:100 EAST LANCASTER AVENUE
Mailing Address - Street 2:LANKENAU MEDICAL BLDG - SUITE 203W
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096
Mailing Address - Country:US
Mailing Address - Phone:610-642-0259
Mailing Address - Fax:610-896-6405
Practice Address - Street 1:100 E LANCASTER AVE. SUITE 203W
Practice Address - Street 2:LANKENAU MEDICAL BUILDING SOUTH
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096
Practice Address - Country:US
Practice Address - Phone:610-642-0259
Practice Address - Fax:610-896-6405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-025340-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty