Provider Demographics
NPI:1578175733
Name:COLUMBIA DENTAL LLC
Entity Type:Organization
Organization Name:COLUMBIA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZZLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-586-3201
Mailing Address - Street 1:2685 ROSEBAY DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17408-4069
Mailing Address - Country:US
Mailing Address - Phone:717-586-3201
Mailing Address - Fax:
Practice Address - Street 1:846 LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:PA
Practice Address - Zip Code:17512-2206
Practice Address - Country:US
Practice Address - Phone:717-586-3201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA8669500005Medicaid