Provider Demographics
NPI:1912172263
Name:PHILIPSBURG FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PHILIPSBURG FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOLENE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVLAK-VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:814-557-5114
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:PHILIPSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16866-0060
Mailing Address - Country:US
Mailing Address - Phone:814-342-1101
Mailing Address - Fax:
Practice Address - Street 1:109 N CENTRE ST
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-1661
Practice Address - Country:US
Practice Address - Phone:814-342-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031452L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001819412Medicaid