Provider Demographics
NPI:1083103311
Name:CAVALANCIA ORTHODONTIC GROUP, PLLC
Entity Type:Organization
Organization Name:CAVALANCIA ORTHODONTIC GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAVALANCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSDD
Authorized Official - Phone:724-463-7700
Mailing Address - Street 1:152 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-1983
Mailing Address - Country:US
Mailing Address - Phone:724-463-7700
Mailing Address - Fax:724-463-7738
Practice Address - Street 1:152 N 5TH ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-1983
Practice Address - Country:US
Practice Address - Phone:724-463-7700
Practice Address - Fax:724-463-7738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023571L1223X0400X
PADS0399611223X0400X
PADS0411991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024481510001Medicaid