Healthcare Provider Details

I. General information

NPI: 1013090034
Provider Name (Legal Business Name): SPA DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 VENANGO AVE
CAMBRIDGE SPRINGS PA
16403
US

IV. Provider business mailing address

750 VENANGO AVE
CAMBRIDGE SPRINGS PA
16403
US

V. Phone/Fax

Practice location:
  • Phone: 814-398-2656
  • Fax: 814-398-1438
Mailing address:
  • Phone: 814-398-2656
  • Fax: 814-398-1438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS028556L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS017224L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS028556L
License Number StatePA

VIII. Authorized Official

Name: DR. MARIE D CROCKER
Title or Position: OWNER
Credential: D.D.S.
Phone: 814-398-2656