Provider Demographics
NPI:1356462337
Name:NITTANY DENTAL, INC.
Entity Type:Organization
Organization Name:NITTANY DENTAL, INC.
Other - Org Name:NITTANY DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:JEANMENNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:814-238-0088
Mailing Address - Street 1:2601 GATEWAY DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-3213
Mailing Address - Country:US
Mailing Address - Phone:814-238-0088
Mailing Address - Fax:
Practice Address - Street 1:2601 GATEWAY DR
Practice Address - Street 2:SUITE 250
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-3213
Practice Address - Country:US
Practice Address - Phone:814-238-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0353491223G0001X
PADS0354521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty