Provider Demographics
NPI:1093233439
Name:DISANTO, MARY (PHDH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DISANTO
Suffix:
Gender:F
Credentials:PHDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:MC KEES ROCKS
Mailing Address - State:PA
Mailing Address - Zip Code:15136-3808
Mailing Address - Country:US
Mailing Address - Phone:412-771-6462
Mailing Address - Fax:412-771-5887
Practice Address - Street 1:710 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:MC KEES ROCKS
Practice Address - State:PA
Practice Address - Zip Code:15136-3808
Practice Address - Country:US
Practice Address - Phone:412-771-6462
Practice Address - Fax:412-771-5887
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH000577124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist