Provider Demographics
NPI:1720526130
Name:TEMPLE UNIVERSITY
Entity Type:Organization
Organization Name:TEMPLE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CHAIR OF PERIODONTOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:KEISUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WADA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-707-7667
Mailing Address - Street 1:3223 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5007
Mailing Address - Country:US
Mailing Address - Phone:215-707-5774
Mailing Address - Fax:
Practice Address - Street 1:3223 N BROAD ST
Practice Address - Street 2:DEPT OF PERIODONTOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-5774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014149551223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty