Provider Demographics
NPI:1427392943
Name:WESTERN PENNSYLVANIA DENTAL GROUP
Entity Type:Organization
Organization Name:WESTERN PENNSYLVANIA DENTAL GROUP
Other - Org Name:CHESTNUT HILLS DENTAL JOHNSTOWN UPPER YODER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:322 WARREN ST STE 150
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-3443
Mailing Address - Country:US
Mailing Address - Phone:814-619-2410
Mailing Address - Fax:
Practice Address - Street 1:322 WARREN ST STE 150
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-3443
Practice Address - Country:US
Practice Address - Phone:814-619-2410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN PENNSYLVANIA DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-21
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
PADS029676L261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty