Provider Demographics
NPI:1891711388
Name:MIMOSA FAMILY DENTISTRY, PC.
Entity Type:Organization
Organization Name:MIMOSA FAMILY DENTISTRY, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LOC
Authorized Official - Middle Name:NGUYEN
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-838-1338
Mailing Address - Street 1:117 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-2303
Mailing Address - Country:US
Mailing Address - Phone:717-838-1338
Mailing Address - Fax:717-838-7003
Practice Address - Street 1:117 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-2303
Practice Address - Country:US
Practice Address - Phone:717-838-1338
Practice Address - Fax:717-838-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-027312-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA485649OtherINSURANCE