Provider Demographics
NPI:1598190621
Name:PA-FM DENTAL PC
Entity Type:Organization
Organization Name:PA-FM DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRM
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTOLLINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-273-8204
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:866-273-8204
Mailing Address - Fax:866-803-4943
Practice Address - Street 1:508 BRIGHTON CT
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-9693
Practice Address - Country:US
Practice Address - Phone:866-273-8204
Practice Address - Fax:866-803-4943
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASPEN DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA29654122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty