MEDICARE: CDA NORTH POCONO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1811694946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CDA NORTH POCONO LLC

Provider Business Mailing Address
First Line	:	747 BLUE SHUTTERS RD
Second Line	:
City	:	ROARING BROOK TWP
State	:	PA
Zip	:	18444-7626
Country	:	US
Telephone Number	:	570-842-4211
Fax Number	:	570-842-4211

Provider Business Practice Location Address
First Line	:	747 BLUE SHUTTERS RD
Second Line	:
City	:	ROARING BROOK TWP
State	:	PA
Zip	:	18444-7626
Country	:	US
Telephone Number	:	570-842-4211
Fax Number	:	570-842-4211

Authorized Official
Title or Position	:	CONTRACT/CREDENTIALING MANAGER
Name	:	DANIELLE WILKES
Credential	:
Telephone Number	:	570-876-4488

Provider Enumeration Date	:	02/09/2023
Last Update Date	:	02/09/2023

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