Provider Demographics
NPI:1649566738
Name:TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY COMMUNITY DENTAL CLINIC
Entity Type:Organization
Organization Name:TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY COMMUNITY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-707-7756
Mailing Address - Street 1:3223 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5007
Mailing Address - Country:US
Mailing Address - Phone:215-707-7756
Mailing Address - Fax:215-707-5885
Practice Address - Street 1:3223 N. BROAD ST.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-7756
Practice Address - Fax:215-707-5885
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018795L261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental