Provider Demographics
NPI:1619260155
Name:CONSHOHOCKEN DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:CONSHOHOCKEN DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WANSUK
Authorized Official - Middle Name:SETH
Authorized Official - Last Name:SEO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-828-3535
Mailing Address - Street 1:200 W RIDGE PIKE
Mailing Address - Street 2:SUITE #129
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-3702
Mailing Address - Country:US
Mailing Address - Phone:610-828-3535
Mailing Address - Fax:610-828-3558
Practice Address - Street 1:200 W RIDGE PIKE
Practice Address - Street 2:SUITE #129
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-3702
Practice Address - Country:US
Practice Address - Phone:610-828-3535
Practice Address - Fax:610-828-3558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038105122300000X
PADS0366121223G0001X
PADS0354841223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102564482Medicaid