1760737662 NPI number — HAVEN ORTHODONTICS, PC

Table of content: (NPI 1760737662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760737662 NPI number — HAVEN ORTHODONTICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVEN ORTHODONTICS, 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:
POTTSVILLE ORTHODONTICS, PC (FICTITIOUS NAME)
Provider Other Organization Name Type Code:
5
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:
1760737662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHUYLKILL HAVEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17972-1240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-385-1344
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHUYLKILL HAVEN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17972-1240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-385-1344
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HARTMAN
Authorized Official First Name:
JASON
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT/ORTHODONTIST
Authorized Official Telephone Number:
570-385-1344

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  DS038055 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1023923970001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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