Provider Demographics
NPI:1710488689
Name:GENTLE DENTISTRY OF LANCASTER, PLLC
Entity Type:Organization
Organization Name:GENTLE DENTISTRY OF LANCASTER, PLLC
Other - Org Name:EASTSIDE DENTAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:595 MADISON AVE FL 27
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1649
Mailing Address - Country:US
Mailing Address - Phone:212-758-9498
Mailing Address - Fax:
Practice Address - Street 1:595 MADISON AVE FL 27
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1649
Practice Address - Country:US
Practice Address - Phone:212-758-9498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENTLE DENTISTRY OF LANCASTER, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty