Provider Demographics
NPI:1386638716
Name:DAGOSTINO, ALEGRIA (DMD)
Entity type:Individual
Prefix:
First Name:ALEGRIA
Middle Name:
Last Name:DAGOSTINO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2943
Mailing Address - Country:US
Mailing Address - Phone:215-743-3700
Mailing Address - Fax:215-743-3706
Practice Address - Street 1:6404 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2943
Practice Address - Country:US
Practice Address - Phone:215-743-3700
Practice Address - Fax:215-743-3706
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029850L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001964084Medicaid