Provider Demographics
NPI:1366507253
Name:PEDIATRIC DENTAL ASSOC LTD
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL ASSOC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-743-3700
Mailing Address - Street 1:6404 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19149
Mailing Address - Country:US
Mailing Address - Phone:215-743-3700
Mailing Address - Fax:215-743-3715
Practice Address - Street 1:7 E SKIPPACK PIKE
Practice Address - Street 2:SUITE 100
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-5308
Practice Address - Country:US
Practice Address - Phone:215-653-0420
Practice Address - Fax:215-653-0808
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC DENTAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-22
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025205L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty