Provider Demographics
NPI:1619225810
Name:PENNSYLVANIA CENTER FOR DENTAL SLEEP MEDICINE PC
Entity Type:Organization
Organization Name:PENNSYLVANIA CENTER FOR DENTAL SLEEP MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:717-632-1332
Mailing Address - Street 1:1225 CARLISLE ST STE 1B
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-1207
Mailing Address - Country:US
Mailing Address - Phone:717-632-1332
Mailing Address - Fax:270-637-0207
Practice Address - Street 1:1225 CARLISLE ST STE 1B
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331
Practice Address - Country:US
Practice Address - Phone:717-632-1332
Practice Address - Fax:270-637-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA24985122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1619225810Medicare NSC