Provider Demographics
NPI:1295001428
Name:MILLERSVILLE DENTAL LLC
Entity Type:Organization
Organization Name:MILLERSVILLE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEMBER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:A
Authorized Official - Last Name:PESTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:717-871-9002
Mailing Address - Street 1:525 LEAMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17551-1109
Mailing Address - Country:US
Mailing Address - Phone:717-871-9002
Mailing Address - Fax:
Practice Address - Street 1:525 LEAMAN AVE
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17551-1109
Practice Address - Country:US
Practice Address - Phone:717-871-9002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026925L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty