Provider Demographics
NPI:1811295181
Name:ERIE DENTAL SLEEP THERAPY, LLC
Entity type:Organization
Organization Name:ERIE DENTAL SLEEP THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:814-836-7777
Mailing Address - Street 1:3736 STERRETTANIA RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-2829
Mailing Address - Country:US
Mailing Address - Phone:814-836-2866
Mailing Address - Fax:814-217-6811
Practice Address - Street 1:3736 STERRETTANIA RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-2829
Practice Address - Country:US
Practice Address - Phone:814-836-2866
Practice Address - Fax:814-217-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
PADS023159L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6524740001OtherPTAN