Provider Demographics
NPI:1528364932
Name:DENTAL SPECIALISTS OF NORTHEAST PA ROOT CANAL & IMPLANT DENTISTRY PC
Entity Type:Organization
Organization Name:DENTAL SPECIALISTS OF NORTHEAST PA ROOT CANAL & IMPLANT DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MANCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DSS
Authorized Official - Phone:570-459-2100
Mailing Address - Street 1:905 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-2707
Mailing Address - Country:US
Mailing Address - Phone:570-459-2100
Mailing Address - Fax:570-459-1617
Practice Address - Street 1:905 W 15TH ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-2707
Practice Address - Country:US
Practice Address - Phone:570-459-2100
Practice Address - Fax:570-459-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017029L1223E0200X
PADS0350591223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty