Provider Demographics
NPI:1114523487
Name:LA DENTAL INC LEVI EVALT DDS DENTAL EXCELLENCE
Entity Type:Organization
Organization Name:LA DENTAL INC LEVI EVALT DDS DENTAL EXCELLENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:EVALT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:814-664-2012
Mailing Address - Street 1:209 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-1626
Mailing Address - Country:US
Mailing Address - Phone:814-664-2012
Mailing Address - Fax:814-964-4055
Practice Address - Street 1:209 N CENTER ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-1626
Practice Address - Country:US
Practice Address - Phone:814-664-2012
Practice Address - Fax:814-964-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001967890Medicaid
PA000870813Medicaid
PA102543929Medicaid