Provider Demographics
NPI:1982601332
Name:MIFFLIN-JUNIATA DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:MIFFLIN-JUNIATA DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KINSLOW
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:717-447-1898
Mailing Address - Street 1:31 S DORCAS ST
Mailing Address - Street 2:COMPASS BLDG. SUITE E
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-2110
Mailing Address - Country:US
Mailing Address - Phone:717-447-1898
Mailing Address - Fax:717-447-1891
Practice Address - Street 1:31 S DORCAS ST
Practice Address - Street 2:COMPASS BLDG. SUITE E
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-2110
Practice Address - Country:US
Practice Address - Phone:717-447-1898
Practice Address - Fax:717-447-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAD5035955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018401110002Medicaid