Provider Demographics
NPI:1164514683
Name:JOHNSONBURG DENTAL CENTER
Entity Type:Organization
Organization Name:JOHNSONBURG DENTAL CENTER
Other - Org Name:KEYSTONE RURAL HEALTH CONSORTIA, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-486-1115
Mailing Address - Street 1:81 CLARION RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSONBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15845-1656
Mailing Address - Country:US
Mailing Address - Phone:814-965-5444
Mailing Address - Fax:814-965-2238
Practice Address - Street 1:81 CLARION RD
Practice Address - Street 2:
Practice Address - City:JOHNSONBURG
Practice Address - State:PA
Practice Address - Zip Code:15845-1656
Practice Address - Country:US
Practice Address - Phone:814-965-5444
Practice Address - Fax:814-965-2238
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEYSTONE RURAL HEALTH CONSORTIA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-29
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental