Provider Demographics
NPI:1417293739
Name:IMPLANT DENTISTRY ASSOCIATES P.C.
Entity Type:Organization
Organization Name:IMPLANT DENTISTRY ASSOCIATES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-231-1177
Mailing Address - Street 1:234 MALL BLVD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2954
Mailing Address - Country:US
Mailing Address - Phone:484-231-1177
Mailing Address - Fax:484-231-8964
Practice Address - Street 1:234 MALL BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2954
Practice Address - Country:US
Practice Address - Phone:484-231-1177
Practice Address - Fax:484-231-8964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024390L1223P0300X
PADS027440L1223P0700X
PADS035811L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty