Provider Demographics
NPI:1649790247
Name:VAN DEN DRIES, SIERRA ROSE (DMD)
Entity type:Individual
Prefix:DR
First Name:SIERRA
Middle Name:ROSE
Last Name:VAN DEN DRIES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 MARKET ST UNIT 404
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1355
Mailing Address - Country:US
Mailing Address - Phone:210-286-6002
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-662-8221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0413461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice