Provider Demographics
NPI: | 1174188486 |
---|---|
Name: | DAY DENTAL ANESTHESIA |
Entity Type: | Organization |
Organization Name: | DAY DENTAL ANESTHESIA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DENTIST ANESTHESIOLOGIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BREANNA |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | DAY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD, DA |
Authorized Official - Phone: | 814-244-7241 |
Mailing Address - Street 1: | PO BOX 181 |
Mailing Address - Street 2: | |
Mailing Address - City: | NICKTOWN |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 15762-0181 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 814-244-7241 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2636 KILLEN SCHOOL ROAD |
Practice Address - Street 2: | |
Practice Address - City: | NICKTOWN |
Practice Address - State: | PA |
Practice Address - Zip Code: | 15762 |
Practice Address - Country: | US |
Practice Address - Phone: | 814-244-7241 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-05-02 |
Last Update Date: | 2019-05-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223D0004X | Dental Providers | Dentist | Dentist Anesthesiologist | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 1031028020001 | Medicaid |