Provider Demographics
NPI:1760578934
Name:SMATLAK, PAUL TIMOTHY
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:TIMOTHY
Last Name:SMATLAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-2303
Mailing Address - Country:US
Mailing Address - Phone:814-938-8554
Mailing Address - Fax:814-938-8559
Practice Address - Street 1:203 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2303
Practice Address - Country:US
Practice Address - Phone:814-938-8554
Practice Address - Fax:814-938-8559
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020705L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA251676034OtherTAX IDENTIFICATION NUMBER
PA0010829130001Medicaid