Provider Demographics
NPI:1639491046
Name:THREE RIVERS DENTAL GROUP/JENNERSTOWN LLC
Entity Type:Organization
Organization Name:THREE RIVERS DENTAL GROUP/JENNERSTOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANA BIANCA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:724-961-4363
Mailing Address - Street 1:1609 PITT STREET
Mailing Address - Street 2:
Mailing Address - City:JENNERSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15527
Mailing Address - Country:US
Mailing Address - Phone:814-629-6621
Mailing Address - Fax:814-629-6622
Practice Address - Street 1:1609 PITT STREET
Practice Address - Street 2:
Practice Address - City:JENNERSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15527
Practice Address - Country:US
Practice Address - Phone:814-629-6621
Practice Address - Fax:814-629-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty