Provider Demographics
NPI:1275694283
Name:WESTERN PENNSYLVANIA DENTAL GROUP
Entity Type:Organization
Organization Name:WESTERN PENNSYLVANIA DENTAL GROUP
Other - Org Name:CHESTNUT HILLS DENTAL HOMER CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:234 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOMER CITY
Mailing Address - State:PA
Mailing Address - Zip Code:15748-1560
Mailing Address - Country:US
Mailing Address - Phone:724-479-8071
Mailing Address - Fax:724-479-4271
Practice Address - Street 1:234 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMER CITY
Practice Address - State:PA
Practice Address - Zip Code:15748-1560
Practice Address - Country:US
Practice Address - Phone:724-479-8071
Practice Address - Fax:724-479-4271
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN PENNSYLVANIA DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022773-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty