Provider Demographics
NPI:1912103235
Name:BIG SPRING DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:BIG SPRING DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:SHOWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:717-776-1228
Mailing Address - Street 1:85 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:NEWVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17241-1405
Mailing Address - Country:US
Mailing Address - Phone:717-776-1228
Mailing Address - Fax:717-754-0755
Practice Address - Street 1:85 S HIGH ST
Practice Address - Street 2:
Practice Address - City:NEWVILLE
Practice Address - State:PA
Practice Address - Zip Code:17241-1405
Practice Address - Country:US
Practice Address - Phone:717-776-1228
Practice Address - Fax:717-754-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-24
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0356471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty