Provider Demographics
NPI:1972673010
Name:PEDIATRIC DENTAL CARE PC, INC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL CARE PC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:KILARESKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:814-238-7120
Mailing Address - Street 1:1019 GHANER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORT MATILDA
Mailing Address - State:PA
Mailing Address - Zip Code:16870-7201
Mailing Address - Country:US
Mailing Address - Phone:814-238-7120
Mailing Address - Fax:814-238-2981
Practice Address - Street 1:1019 GHANER RD STE 100
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870-7201
Practice Address - Country:US
Practice Address - Phone:814-238-7120
Practice Address - Fax:814-238-2981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-031216-L1223P0221X
PADS-019843-L1223P0221X
PADS-036188-L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015435680001Medicaid