Provider Demographics
NPI:1497562680
Name:STATE COLLEGE FAMILY DENTISTRY
Entity type:Organization
Organization Name:STATE COLLEGE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-238-6734
Mailing Address - Street 1:220 REGENT CT STE D
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7969
Mailing Address - Country:US
Mailing Address - Phone:814-238-6734
Mailing Address - Fax:
Practice Address - Street 1:220 REGENT CT STE D
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7969
Practice Address - Country:US
Practice Address - Phone:814-238-6734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental