Provider Demographics
NPI:1740328939
Name:CHESTNUT DENTAL ARTS
Entity type:Organization
Organization Name:CHESTNUT DENTAL ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-242-0670
Mailing Address - Street 1:3 WEST GOWEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119
Mailing Address - Country:US
Mailing Address - Phone:215-242-0670
Mailing Address - Fax:215-248-3874
Practice Address - Street 1:3 WEST GOWEN AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119
Practice Address - Country:US
Practice Address - Phone:215-242-0670
Practice Address - Fax:215-248-3874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025356L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty