Provider Demographics
NPI:1134477425
Name:AFFILIATED PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:AFFILIATED PEDIATRIC DENTISTRY
Other - Org Name:ROSS M. WEZMAR DDS PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEZMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PC
Authorized Official - Phone:570-346-7760
Mailing Address - Street 1:313 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1221
Mailing Address - Country:US
Mailing Address - Phone:570-346-7760
Mailing Address - Fax:570-346-9002
Practice Address - Street 1:313 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1221
Practice Address - Country:US
Practice Address - Phone:570-346-7760
Practice Address - Fax:570-346-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA17699305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005246180003OtherMEDICAL ASSISTANCE
PA1013232140003OtherMEDICAL ASSISTANCE
PA0005246180005OtherMEDICAL ASSISTANCE
PA1023077430004OtherMEDICAL ASSISTANCE
PA1024923650003OtherMEDICAL ASSISTANCE
PA1013232140005OtherMEDICAL ASSISTANCE
PA1024923650001OtherMEDICAL ASSISTANCE
PA1023077430001OtherMEDICAL ASSISTANCE