Provider Demographics
NPI:1639370661
Name:MAIN STREET DENTAL CENTER CITY PC
Entity Type:Organization
Organization Name:MAIN STREET DENTAL CENTER CITY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:EIDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FAGD
Authorized Official - Phone:215-627-1995
Mailing Address - Street 1:1048 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1935
Mailing Address - Country:US
Mailing Address - Phone:215-627-1995
Mailing Address - Fax:215-627-1999
Practice Address - Street 1:1048 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1935
Practice Address - Country:US
Practice Address - Phone:215-627-1995
Practice Address - Fax:215-627-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019673L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty