Provider Demographics
NPI:1437902061
Name:CENTURY DENTAL STR LLC
Entity Type:Organization
Organization Name:CENTURY DENTAL STR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGE
Authorized Official - Prefix:MISS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-876-4488
Mailing Address - Street 1:17 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-2001
Mailing Address - Country:US
Mailing Address - Phone:570-420-9332
Mailing Address - Fax:
Practice Address - Street 1:17 S 6TH ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2001
Practice Address - Country:US
Practice Address - Phone:570-420-9332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty