Provider Demographics
NPI:1508202862
Name:PEDICINO, ANTHONY M (DDS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:M
Last Name:PEDICINO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 WELSH RD
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4655
Mailing Address - Country:US
Mailing Address - Phone:215-464-6663
Mailing Address - Fax:215-464-4949
Practice Address - Street 1:1916 WELSH RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4655
Practice Address - Country:US
Practice Address - Phone:215-464-6663
Practice Address - Fax:215-464-4949
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA023689122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist