Provider Demographics
NPI:1174015671
Name:CD PENNSYLVANIA DENTAL, P.C.
Entity Type:Organization
Organization Name:CD PENNSYLVANIA DENTAL, P.C.
Other - Org Name:DRS. MELMAN, RAVETT & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING & PAYER REL
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-808-4984
Mailing Address - Street 1:9825 KENWOOD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6252
Mailing Address - Country:US
Mailing Address - Phone:513-609-4076
Mailing Address - Fax:513-448-0511
Practice Address - Street 1:6012 GREENE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2726
Practice Address - Country:US
Practice Address - Phone:215-843-9400
Practice Address - Fax:215-843-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty