Provider Demographics
NPI:1326684606
Name:OUTSIDE BONES PC
Entity Type:Organization
Organization Name:OUTSIDE BONES PC
Other - Org Name:COMPLETE CARE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLINKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-697-3087
Mailing Address - Street 1:1411 EMERICK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-2612
Mailing Address - Country:US
Mailing Address - Phone:917-523-9800
Mailing Address - Fax:
Practice Address - Street 1:1300 MACDADE BLVD UNIT 5
Practice Address - Street 2:
Practice Address - City:WOODLYN
Practice Address - State:PA
Practice Address - Zip Code:19094-1500
Practice Address - Country:US
Practice Address - Phone:608-697-3087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty