Provider Demographics
NPI:1639558950
Name:PEDIATRIC DENTAL ASSOCIATES, LTD
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:215-707-1016
Mailing Address - Street 1:2301 E ALLEGHENY AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4427
Mailing Address - Country:US
Mailing Address - Phone:215-707-1030
Mailing Address - Fax:215-707-0083
Practice Address - Street 1:2301 E ALLEGHENY AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4427
Practice Address - Country:US
Practice Address - Phone:215-707-1030
Practice Address - Fax:215-707-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0368461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005299280006Medicaid