Provider Demographics
NPI:1881924140
Name:SPARK ORTHODONTICS, P.C.
Entity type:Organization
Organization Name:SPARK ORTHODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:610-865-2777
Mailing Address - Street 1:5318 ALLENTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:PA
Mailing Address - Zip Code:19560-1249
Mailing Address - Country:US
Mailing Address - Phone:610-865-2777
Mailing Address - Fax:610-929-1110
Practice Address - Street 1:701 W UNION BLVD
Practice Address - Street 2:SUITE 11
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-3700
Practice Address - Country:US
Practice Address - Phone:610-865-2777
Practice Address - Fax:610-865-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-10
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0380551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023923970001Medicaid