Provider Demographics
NPI:1225254634
Name:AQUELINE ELIZABETH KIRBY MEMORIAL HEALTH CENTER DENTAL CLINIC
Entity Type:Organization
Organization Name:AQUELINE ELIZABETH KIRBY MEMORIAL HEALTH CENTER DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPPELLINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-822-4178
Mailing Address - Street 1:71 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-1312
Mailing Address - Country:US
Mailing Address - Phone:570-822-4278
Mailing Address - Fax:570-825-9926
Practice Address - Street 1:71 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-1312
Practice Address - Country:US
Practice Address - Phone:570-822-4278
Practice Address - Fax:570-825-9926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007139380002OtherMEDICAL ASSISTANCE
PW828141OtherGATEWAY
PA167782OtherUNISON