Provider Demographics
NPI:1598034639
Name:UNIVERSITY OF PENN-DENTAL MED ASST
Entity Type:Organization
Organization Name:UNIVERSITY OF PENN-DENTAL MED ASST
Other - Org Name:PENN PERSONALIZED CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-2450
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:1 EAST PAVILION
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-662-2450
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:1 EAST PAVILION
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-662-2450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028425E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty