Provider Demographics
NPI:1801097811
Name:JEFFREY P DECROSTA DDS PC
Entity type:Organization
Organization Name:JEFFREY P DECROSTA DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHARINE
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:DECROSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-691-6200
Mailing Address - Street 1:627 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-5220
Mailing Address - Country:US
Mailing Address - Phone:610-691-6200
Mailing Address - Fax:610-691-1840
Practice Address - Street 1:627 W BROAD ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-5220
Practice Address - Country:US
Practice Address - Phone:610-691-6200
Practice Address - Fax:610-691-1840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA340380OtherUNITED CONCORDIA