Provider Demographics
NPI:1811694946
Name:CDA NORTH POCONO LLC
Entity type:Organization
Organization Name:CDA NORTH POCONO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT/CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-876-4488
Mailing Address - Street 1:747 BLUE SHUTTERS RD
Mailing Address - Street 2:
Mailing Address - City:ROARING BROOK TWP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-7626
Mailing Address - Country:US
Mailing Address - Phone:570-842-4211
Mailing Address - Fax:570-842-4211
Practice Address - Street 1:747 BLUE SHUTTERS RD
Practice Address - Street 2:
Practice Address - City:ROARING BROOK TWP
Practice Address - State:PA
Practice Address - Zip Code:18444-7626
Practice Address - Country:US
Practice Address - Phone:570-842-4211
Practice Address - Fax:570-842-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty