Provider Demographics
NPI:1235344037
Name:EIDELSON, RICHARD VICTOR (DDS, FAGD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:VICTOR
Last Name:EIDELSON
Suffix:
Gender:M
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1935
Mailing Address - Country:US
Mailing Address - Phone:215-627-1995
Mailing Address - Fax:215-627-1999
Practice Address - Street 1:1048 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1935
Practice Address - Country:US
Practice Address - Phone:215-627-1995
Practice Address - Fax:215-627-1999
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019673L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice