Provider Demographics
NPI:1669082632
Name:NEPA DENTAL GROUP, INC
Entity type:Organization
Organization Name:NEPA DENTAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-655-7645
Mailing Address - Street 1:457 N MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-2185
Mailing Address - Country:US
Mailing Address - Phone:570-655-7645
Mailing Address - Fax:570-299-7427
Practice Address - Street 1:920 WYOMING AVE STE 104
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-3970
Practice Address - Country:US
Practice Address - Phone:570-283-2422
Practice Address - Fax:570-283-1492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty