Basic Information
| Provider Information | |||||||||
| NPI: | 1568563070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIELDING | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | FRED | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E LEHIGH AVE | ||||||||
| Address2: | PM2 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191251011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073613 | ||||||||
| FaxNumber: | 2157075405 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E LEHIGH AVE | ||||||||
| Address2: | PM2 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191251011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073613 | ||||||||
| FaxNumber: | 2157075405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 12/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | DS016909L | PA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0582812 | 01 | PA | AETNA HEALTHCARE | OTHER | 01684301 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 2000631 | 01 | PA | KEYSTONE CENTRAL | OTHER | 0060874000 | 01 | PA | KEYSTONE EAST | OTHER |