Provider Demographics
NPI:1255664819
Name:TIOGA DENTAL SERVICES
Entity Type:Organization
Organization Name:TIOGA DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:RISNER-BAUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FADPD
Authorized Official - Phone:570-827-0145
Mailing Address - Street 1:34 E LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16929-8801
Mailing Address - Country:US
Mailing Address - Phone:570-724-9145
Mailing Address - Fax:570-724-5397
Practice Address - Street 1:34 E LAWRENCE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:PA
Practice Address - Zip Code:16929-8801
Practice Address - Country:US
Practice Address - Phone:570-724-9145
Practice Address - Fax:570-724-5397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental