Provider Demographics
NPI:1609275734
Name:DENTAL PROFESSIONALS OF PENNSYLVANIA P C
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF PENNSYLVANIA P C
Other - Org Name:ROLLING RIDGE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:432 ROLLING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7640
Mailing Address - Country:US
Mailing Address - Phone:814-237-1777
Mailing Address - Fax:814-237-5245
Practice Address - Street 1:432 ROLLING RIDGE DR
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7640
Practice Address - Country:US
Practice Address - Phone:814-237-1777
Practice Address - Fax:814-237-5245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF PENNSYLVANIA P C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty