NPIMap

Organization Active NPI

Pennsylvania Dental Group LTD.

  • General Practice Dentistry
  • Philadelphia, PA
National Provider Identifier
1114054962
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
DS18682L Issued in PA
Legal business name
PENNSYLVANIA DENTAL GROUP LTD.
Practice address
3550 Market St
Philadelphia, PA 19104-3329
Phone
(215) 387-0883
Fax
(215) 387-9659
NPI assigned
Feb 28, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. George E. Boudreau
Title
President
Phone
(215) 387-0883

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X DS18682L PA Primary

Addresses

Primary practice location

3550 Market St
Philadelphia, PA 19104-3329

Mailing address

3550 Market St
Philadelphia, PA 19104-3329
Phone (215) 387-0883

National Provider Directory

National Provider Directory
Tax ID family
Pennsylvania Dental Group LTD2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172620800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1114054962",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3550 MARKET ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191043329",
            "telephone_number": "215-387-0883",
            "fax_number": "215-387-9659"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3550 MARKET ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191043329",
            "telephone_number": "215-387-0883",
            "fax_number": "215-387-9659"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENNSYLVANIA DENTAL GROUP LTD.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-28",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BOUDREAU",
        "authorized_official_first_name": "GEORGE",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "215-387-0883",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "PA",
            "license": "DS18682L",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.