Provider Demographics
NPI:1235177247
Name:MOUNTAIN, LAJUAN M (DMD)
Entity Type:Individual
Prefix:
First Name:LAJUAN
Middle Name:M
Last Name:MOUNTAIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 S GEORGE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17401-1408
Mailing Address - Country:US
Mailing Address - Phone:717-846-8546
Mailing Address - Fax:717-854-0377
Practice Address - Street 1:415 E BOUNDARY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-2811
Practice Address - Country:US
Practice Address - Phone:717-846-5174
Practice Address - Fax:717-845-4884
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0361951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA248134OtherDENTAL BENEFIT PROVIDERS
PA101296402Medicaid
PA1734162OtherUNITED CONCORDIA
PADS036195OtherDELTA DENTAL
PA169245OtherUNISON
PA9179591OtherDORAL DENTAL