Provider Demographics
NPI:1205280310
Name:STREAMSIDE DENTAL
Entity type:Organization
Organization Name:STREAMSIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:KURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:814-934-7161
Mailing Address - Street 1:109 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-1259
Mailing Address - Country:US
Mailing Address - Phone:814-934-7161
Mailing Address - Fax:
Practice Address - Street 1:109 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-1259
Practice Address - Country:US
Practice Address - Phone:814-934-7161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental