Provider Demographics
NPI:1679618433
Name:MAIN LINE DENTAL GROUP PC
Entity type:Organization
Organization Name:MAIN LINE DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-971-0717
Mailing Address - Street 1:744 W LANCASTER AVE
Mailing Address - Street 2:DEVON SQUARE II SUITE 115
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-2523
Mailing Address - Country:US
Mailing Address - Phone:610-971-0717
Mailing Address - Fax:610-971-9781
Practice Address - Street 1:744 WEST LANCASTER AVE
Practice Address - Street 2:DEVON SQUARE II SUITE 115
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-2523
Practice Address - Country:US
Practice Address - Phone:610-971-0717
Practice Address - Fax:610-971-9781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022342L1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty