Provider Demographics
NPI:1598281396
Name:GTOWN DENTAL LLC
Entity Type:Organization
Organization Name:GTOWN DENTAL LLC
Other - Org Name:G TOWN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-335-2181
Mailing Address - Street 1:5616 GERMANTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2228
Mailing Address - Country:US
Mailing Address - Phone:267-335-2181
Mailing Address - Fax:
Practice Address - Street 1:5616 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2228
Practice Address - Country:US
Practice Address - Phone:267-335-2181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0405261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========Medicaid