Provider Demographics
NPI:1093220105
Name:DAVID A EICHENLAUB & GARY R BODMER, PARTNERS
Entity Type:Organization
Organization Name:DAVID A EICHENLAUB & GARY R BODMER, PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAVONNE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-248-4896
Mailing Address - Street 1:744 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-1425
Mailing Address - Country:US
Mailing Address - Phone:717-248-4896
Mailing Address - Fax:
Practice Address - Street 1:744 VALLEY ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1425
Practice Address - Country:US
Practice Address - Phone:717-248-4896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017307L261QD0000X
PADS021903L261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1811051923OtherGENERAL DENTISTRY
PA1235293341OtherGENERAL DENTISTRY