Provider Demographics
NPI:1093048217
Name:ELECTRIC CITY DENTAL GROUP
Entity Type:Organization
Organization Name:ELECTRIC CITY DENTAL GROUP
Other - Org Name:FOREST CITY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARTLAND
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-383-0784
Mailing Address - Street 1:305 SCHOOL SIDE DR
Mailing Address - Street 2:
Mailing Address - City:THROOP
Mailing Address - State:PA
Mailing Address - Zip Code:18512-1456
Mailing Address - Country:US
Mailing Address - Phone:570-383-0784
Mailing Address - Fax:
Practice Address - Street 1:117 MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:PA
Practice Address - Zip Code:18421-1440
Practice Address - Country:US
Practice Address - Phone:570-785-3000
Practice Address - Fax:570-785-3175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0352001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty