Provider Demographics
NPI:1558080804
Name:SPROUT PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:SPROUT PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ROSALIE
Authorized Official - Last Name:SCHLOESSER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-253-0358
Mailing Address - Street 1:554 HAMLIN HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE ARIEL
Mailing Address - State:PA
Mailing Address - Zip Code:18436-9319
Mailing Address - Country:US
Mailing Address - Phone:267-324-7933
Mailing Address - Fax:570-352-3395
Practice Address - Street 1:487 NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-4509
Practice Address - Country:US
Practice Address - Phone:267-324-7933
Practice Address - Fax:570-352-3395
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPROUT PEDIATRIC DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102769720-0003Medicaid