Provider Demographics
NPI:1326417551
Name:PIMD DENTAL
Entity Type:Organization
Organization Name:PIMD DENTAL
Other - Org Name:PIMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHENET
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:786-319-2474
Mailing Address - Street 1:7130 RISING SUN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-3957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7130 RISING SUN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-3957
Practice Address - Country:US
Practice Address - Phone:786-319-2474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN INTEGRATIVE MEDICAL & DENTAL CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027302L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty