Provider Demographics
NPI:1346360765
Name:ELVERSON DENTAL CARE, LLC
Entity Type:Organization
Organization Name:ELVERSON DENTAL CARE, LLC
Other - Org Name:SCOTT WALLACE DDS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOLITARSKY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-286-5841
Mailing Address - Street 1:4101 W. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ELVERSON
Mailing Address - State:PA
Mailing Address - Zip Code:19520
Mailing Address - Country:US
Mailing Address - Phone:610-286-5841
Mailing Address - Fax:610-286-0161
Practice Address - Street 1:4101 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELVERSON
Practice Address - State:PA
Practice Address - Zip Code:19520
Practice Address - Country:US
Practice Address - Phone:610-286-5841
Practice Address - Fax:610-286-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026093L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherTIN