Provider Demographics
NPI:1588864631
Name:BRANDYWINE DENTAL SERVICES GROUP
Entity type:Organization
Organization Name:BRANDYWINE DENTAL SERVICES GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-459-1344
Mailing Address - Street 1:1731 WILMINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-8169
Mailing Address - Country:US
Mailing Address - Phone:610-459-1344
Mailing Address - Fax:610-459-0310
Practice Address - Street 1:1731 WILMINGTON PIKE
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-8169
Practice Address - Country:US
Practice Address - Phone:610-459-1344
Practice Address - Fax:610-459-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG100009811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty