Provider Demographics
NPI:1952447534
Name:PENNSYLVANIA DENTAL GROUP LTD
Entity Type:Organization
Organization Name:PENNSYLVANIA DENTAL GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-387-0883
Mailing Address - Street 1:1740 SOUTH ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19146
Mailing Address - Country:US
Mailing Address - Phone:215-387-0883
Mailing Address - Fax:215-387-9659
Practice Address - Street 1:1740 SOUTH ST
Practice Address - Street 2:SUITE 504
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19146
Practice Address - Country:US
Practice Address - Phone:215-545-6334
Practice Address - Fax:215-893-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS18680L122300000X
PADS19260L122300000X
PADS035436122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty