Provider Demographics
NPI:1033383195
Name:AESTHETIC DENTAL GROUP OF UNIONTOWN
Entity Type:Organization
Organization Name:AESTHETIC DENTAL GROUP OF UNIONTOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GWYNN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:724-439-1170
Mailing Address - Street 1:625 CHERRY TREE LN
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-8419
Mailing Address - Country:US
Mailing Address - Phone:724-439-1170
Mailing Address - Fax:
Practice Address - Street 1:625 CHERRY TREE LN
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-8419
Practice Address - Country:US
Practice Address - Phone:724-439-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA030292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty