Provider Demographics
NPI:1659706166
Name:THE SALVATION ARMY
Entity Type:Organization
Organization Name:THE SALVATION ARMY
Other - Org Name:THE SALVATION ARMY - DENTAL CENTER OF JOHNSTOWN
Other - Org Type:Other Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SOUTHWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-620-7329
Mailing Address - Street 1:440 W NYACK RD
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-1753
Mailing Address - Country:US
Mailing Address - Phone:845-620-7200
Mailing Address - Fax:845-620-7615
Practice Address - Street 1:647 MAIN STREET
Practice Address - Street 2:PO BOX 968
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15907-0968
Practice Address - Country:US
Practice Address - Phone:814-539-3110
Practice Address - Fax:814-536-4785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025867L122300000X
251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No251V00000XAgenciesVoluntary or CharitableGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011051320005Medicaid