Provider Demographics
NPI:1326392846
Name:EAGLE CREST PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:EAGLE CREST PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WADENYA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:484-454-3568
Mailing Address - Street 1:31 S EAGLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-3340
Mailing Address - Country:US
Mailing Address - Phone:484-454-3568
Mailing Address - Fax:484-454-3582
Practice Address - Street 1:31 S EAGLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-3340
Practice Address - Country:US
Practice Address - Phone:484-454-3568
Practice Address - Fax:484-454-3582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty