1578966180 NPI number — CHILDRENS GENERAL DENTISTRY PC

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 1578966180 NPI number — CHILDRENS GENERAL DENTISTRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRENS GENERAL DENTISTRY 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:
1578966180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 W LUDLOW ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
SUMMIT HILL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18250-1141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 W LUDLOW ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SUMMIT HILL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18250-1141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-645-2044
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
VERMILLION
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
LOUIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-645-2044

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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