Provider Demographics
NPI:1639619604
Name:DENTAL PROFESSIONALS OF PENNSYLVANIA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF PENNSYLVANIA, P.C.
Other - Org Name:GIBSONIA DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:5161 WILLIAM FLYNN HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-8401
Mailing Address - Country:US
Mailing Address - Phone:724-939-6417
Mailing Address - Fax:
Practice Address - Street 1:5161 WILLIAM FLYNN HWY
Practice Address - Street 2:SUITE B
Practice Address - City:GIBSONIA
Practice Address - State:PA
Practice Address - Zip Code:15044-8401
Practice Address - Country:US
Practice Address - Phone:724-939-6417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF PENNSYLVANIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty