1720157084 NPI number — MOSHANNON VALLEY FAMILY DENTISTRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720157084 NPI number — MOSHANNON VALLEY FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSHANNON VALLEY FAMILY DENTISTRY
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:
1720157084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
439 SPRING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUTZDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16651-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-378-7479
Provider Business Mailing Address Fax Number:
814-378-7439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
439 SPRING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUTZDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16651-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-378-7479
Provider Business Practice Location Address Fax Number:
814-378-7439
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRITTON
Authorized Official First Name:
AMY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
RECEPTIONIST
Authorized Official Telephone Number:
814-378-7479

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DS029496L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: DS031452L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 927201 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0015366400003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1015127030001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0018194120002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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