Provider Demographics
NPI:1356448864
Name:BRADFORD COUNTY DENTAL HEALTH SERV INC
Entity Type:Organization
Organization Name:BRADFORD COUNTY DENTAL HEALTH SERV INC
Other - Org Name:NOT FOR PROFIT
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTAL HYGIENIST CLINICAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:ROH
Authorized Official - Phone:570-265-2069
Mailing Address - Street 1:1 PROGRESS PLAZA
Mailing Address - Street 2:SUITE #6
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-1656
Mailing Address - Country:US
Mailing Address - Phone:570-265-2069
Mailing Address - Fax:570-265-8718
Practice Address - Street 1:1 PROGRESS PLAZA
Practice Address - Street 2:SUITE #6
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-1656
Practice Address - Country:US
Practice Address - Phone:570-265-2069
Practice Address - Fax:570-265-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016485020002Medicaid