Provider Demographics
NPI:1811023856
Name:SUSQUEHANNA VALLEY DENTAL HEALTH ASSOCIATES
Entity Type:Organization
Organization Name:SUSQUEHANNA VALLEY DENTAL HEALTH ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:ORLANDO
Authorized Official - Last Name:PESILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-742-9607
Mailing Address - Street 1:20 SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:PA
Mailing Address - Zip Code:17847-7909
Mailing Address - Country:US
Mailing Address - Phone:570-742-9607
Mailing Address - Fax:
Practice Address - Street 1:20 SCHOOLHOUSE RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:PA
Practice Address - Zip Code:17847-7909
Practice Address - Country:US
Practice Address - Phone:570-742-9607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS176961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019642900001Medicaid