Provider Demographics
NPI:1790015287
Name:BROOKHAVEN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BROOKHAVEN FAMILY DENTISTRY
Other - Org Name:CENTER FOR FAMILY & COSMETIC DENTISTRY AT BROOKHAVEN
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DINESH
Authorized Official - Middle Name:S
Authorized Official - Last Name:TEWARI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-457-5671
Mailing Address - Street 1:4 W BROOKHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-1629
Mailing Address - Country:US
Mailing Address - Phone:610-457-5671
Mailing Address - Fax:610-876-6774
Practice Address - Street 1:4 W BROOKHAVEN RD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-1629
Practice Address - Country:US
Practice Address - Phone:610-457-5671
Practice Address - Fax:610-876-6774
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DREXEL HILL FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0 35539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty