1336597947 NPI number — INDIJU2DENTAL

Table of content: LEONARD H. CALABRESE DO (NPI 1467415265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336597947 NPI number — INDIJU2DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIJU2DENTAL
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:
6
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:
1336597947
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 DUNHAM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUMMELSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17036-8040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-991-8750
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S WATER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17098-1530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-991-8750
Provider Business Practice Location Address Fax Number:
717-566-6047
Provider Enumeration Date:
05/25/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOSS
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
ALLYN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
717-991-8750

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DS029748-L , 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)