Provider Demographics
NPI:1558723494
Name:BRINTON LAKE DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:BRINTON LAKE DENTAL ASSOCIATES, LLC
Other - Org Name:DENTISTS AT BRINTON LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:D'ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-828-8986
Mailing Address - Street 1:145 BRINTON LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342
Mailing Address - Country:US
Mailing Address - Phone:610-459-9663
Mailing Address - Fax:610-459-8290
Practice Address - Street 1:145 BRINTON LAKE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1285
Practice Address - Country:US
Practice Address - Phone:610-459-9963
Practice Address - Fax:610-459-8290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-21
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027954L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty