Healthcare Provider Details

I. General information

NPI: 1881135184
Provider Name (Legal Business Name): ALLISON PARK DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4290 WILLIAM FLYNN HWY
ALLISON PARK PA
15101-1443
US

IV. Provider business mailing address

PO BOX 66
HOUSTON PA
15342-0066
US

V. Phone/Fax

Practice location:
  • Phone: 412-487-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JASON FEDERER
Title or Position: OWNER
Credential:
Phone: 727-463-8284