Provider Demographics
NPI:1336202787
Name:BROOMALL PEDIATRIC DENTISTRY & ORTHODONTICS,P.C.
Entity Type:Organization
Organization Name:BROOMALL PEDIATRIC DENTISTRY & ORTHODONTICS,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST,OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSLEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:484-454-3230
Mailing Address - Street 1:1220 W CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-3339
Mailing Address - Country:US
Mailing Address - Phone:484-454-3230
Mailing Address - Fax:484-455-7186
Practice Address - Street 1:1220 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-3339
Practice Address - Country:US
Practice Address - Phone:484-454-3230
Practice Address - Fax:484-455-7186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1223G0001X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101239157-0001Medicare ID - Type UnspecifiedDEPARTMENT OF WELFARE