Provider Demographics
NPI:1639446057
Name:PAXTANG FAMILY DENTISTRY INC
Entity Type:Organization
Organization Name:PAXTANG FAMILY DENTISTRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:RACHAEL
Authorized Official - Last Name:CARRE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-561-1209
Mailing Address - Street 1:3404 DERRY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-1834
Mailing Address - Country:US
Mailing Address - Phone:717-561-1209
Mailing Address - Fax:717-561-4033
Practice Address - Street 1:3404 DERRY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-1834
Practice Address - Country:US
Practice Address - Phone:717-561-1209
Practice Address - Fax:717-561-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035741122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024184100001Medicaid