NPIMap

Organization Active NPI

Pennsylvania Dental Group LTD

  • Dentist
  • Phila, PA
National Provider Identifier
1952447534
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
DS035436 Issued in PA
Legal business name
PENNSYLVANIA DENTAL GROUP LTD
Practice address
1740 South St
Suite 504
Phila, PA 19146
Phone
(215) 545-6334
Fax
(215) 893-4675
NPI assigned
Jan 30, 2007
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
George E Boudreau, DMDNPI 1447218953
Title
DMD President
Phone
(215) 387-0883

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X DS18680L PA
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X DS19260L PA
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X DS035436 PA Primary

Addresses

Primary practice location

1740 South St
Suite 504
Phila, PA 19146

Mailing address

1740 South St
Suite 504
Phila, PA 19146
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.

Locations

1740 South St
Ste 504
Philadelphia, PA 19146
Phone (215) 545-6334

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1170115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1952447534",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1740 SOUTH ST",
            "address_2": "SUITE 504",
            "city": "PHILA",
            "state": "PA",
            "postal_code": "19146",
            "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": "1740 SOUTH ST",
            "address_2": "SUITE 504",
            "city": "PHILA",
            "state": "PA",
            "postal_code": "19146",
            "telephone_number": "215-545-6334",
            "fax_number": "215-893-4675"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENNSYLVANIA DENTAL GROUP LTD",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-30",
        "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": "DMD PRESIDENT",
        "authorized_official_telephone_number": "215-387-0883",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "PA",
            "license": "DS18680L",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "PA",
            "license": "DS19260L",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "PA",
            "license": "DS035436",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Phila, 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.