Provider Demographics
NPI:1972983609
Name:BROAD AXE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BROAD AXE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HERSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-643-9858
Mailing Address - Street 1:6198 BUTLER PIKE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-2600
Mailing Address - Country:US
Mailing Address - Phone:215-643-9858
Mailing Address - Fax:215-643-9882
Practice Address - Street 1:6198 BUTLER PIKE
Practice Address - Street 2:SUITE 140
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-2600
Practice Address - Country:US
Practice Address - Phone:215-643-9858
Practice Address - Fax:215-643-9882
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERSHMAN FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0390911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty