Provider Demographics
NPI:1760841084
Name:WHITE WILLOW DENTAL ARTS
Entity Type:Organization
Organization Name:WHITE WILLOW DENTAL ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUKOVCAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-410-2049
Mailing Address - Street 1:1413 BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-3152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1244 FORT WASHINGTON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-1743
Practice Address - Country:US
Practice Address - Phone:215-643-0363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039121261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental