Provider Demographics
NPI:1902544711
Name:PEDIATRIC DENTAL EXCELLENCE, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL EXCELLENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-879-3863
Mailing Address - Street 1:3300 HENRY AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1141
Mailing Address - Country:US
Mailing Address - Phone:267-879-3863
Mailing Address - Fax:
Practice Address - Street 1:3300 HENRY AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19129-1141
Practice Address - Country:US
Practice Address - Phone:267-879-3863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty