Provider Demographics
NPI:1801913009
Name:LOYALSOCK DENTAL ASSOCIATES
Entity type:Organization
Organization Name:LOYALSOCK DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-323-6116
Mailing Address - Street 1:1501 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5426
Mailing Address - Country:US
Mailing Address - Phone:570-323-6116
Mailing Address - Fax:570-323-5850
Practice Address - Street 1:1501 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-5426
Practice Address - Country:US
Practice Address - Phone:570-323-6116
Practice Address - Fax:570-323-5850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020882L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty