Provider Demographics
NPI:1093108102
Name:GAUNT FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:GAUNT FAMILY DENTISTRY PC
Other - Org Name:GAUNT FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAUNT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:570-753-5403
Mailing Address - Street 1:107 E CENTRAL AVE
Mailing Address - Street 2:PO BOX 710
Mailing Address - City:AVIS
Mailing Address - State:PA
Mailing Address - Zip Code:17721-8904
Mailing Address - Country:US
Mailing Address - Phone:570-753-5403
Mailing Address - Fax:570-753-5485
Practice Address - Street 1:107 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AVIS
Practice Address - State:PA
Practice Address - Zip Code:17721-8904
Practice Address - Country:US
Practice Address - Phone:570-753-5403
Practice Address - Fax:570-753-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-022420-L261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental