Provider Demographics
NPI:1417465402
Name:DENTAL WIZARD G PC
Entity Type:Organization
Organization Name:DENTAL WIZARD G PC
Other - Org Name:PARADISE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:GENIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-886-9474
Mailing Address - Street 1:2338 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-3716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2338 N FRONT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3716
Practice Address - Country:US
Practice Address - Phone:267-886-9474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty