Provider Demographics
NPI:1124667159
Name:CCD WAYNE FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:CCD WAYNE FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-842-5421
Mailing Address - Street 1:415 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-4202
Mailing Address - Country:US
Mailing Address - Phone:610-688-4578
Mailing Address - Fax:
Practice Address - Street 1:415 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-4202
Practice Address - Country:US
Practice Address - Phone:610-688-4578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-20
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty