Provider Demographics
NPI:1649439613
Name:CHARM PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:CHARM PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOOSUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:SUH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-277-4811
Mailing Address - Street 1:1040 DEKALB PIKE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1812
Mailing Address - Country:US
Mailing Address - Phone:610-277-4811
Mailing Address - Fax:610-277-4896
Practice Address - Street 1:1040 DEKALB PIKE
Practice Address - Street 2:SUITE 100
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422
Practice Address - Country:US
Practice Address - Phone:610-277-4811
Practice Address - Fax:610-277-4896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030062L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102099918001Medicaid
PA1831119916OtherNPI