Provider Demographics
NPI:1013789452
Name:BACK MOUNTAIN PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BACK MOUNTAIN PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PIZANO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:570-885-9531
Mailing Address - Street 1:126 SENECA DR
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1598
Mailing Address - Country:US
Mailing Address - Phone:570-885-9531
Mailing Address - Fax:
Practice Address - Street 1:3784 YALICK PLZ UNIT 1
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-7719
Practice Address - Country:US
Practice Address - Phone:570-456-5566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty