1114150380 NPI number — UNIONTOWN DENTAL CARE PC

Table of content: (NPI 1114150380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114150380 NPI number — UNIONTOWN DENTAL CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIONTOWN DENTAL CARE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114150380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
661 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIONTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15401-2646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-439-4444
Provider Business Mailing Address Fax Number:
724-439-4449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
661 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIONTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15401-2646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-439-4444
Provider Business Practice Location Address Fax Number:
724-439-4449
Provider Enumeration Date:
09/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SHUTSY
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
724-439-4444

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1007529750001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 030220 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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