Provider Demographics
NPI:1275905614
Name:ULTRA DENTAL I, LLC
Entity Type:Organization
Organization Name:ULTRA DENTAL I, LLC
Other - Org Name:ULTRA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EFDA/
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GPHN
Authorized Official - Suffix:
Authorized Official - Credentials:EFDA
Authorized Official - Phone:717-741-5707
Mailing Address - Street 1:233 PAULINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402
Mailing Address - Country:US
Mailing Address - Phone:717-741-5707
Mailing Address - Fax:717-741-5505
Practice Address - Street 1:233 PAULINE DRIVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402
Practice Address - Country:US
Practice Address - Phone:717-741-5707
Practice Address - Fax:717-741-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024334L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102032866001OtherPROMISE ID
PA1020328750Medicaid
PA1020328750Medicaid