Healthcare Provider Details

I. General information

NPI: 1083683866
Provider Name (Legal Business Name): ANDREW N MACK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 E MAIN ST
CANTON PA
17724-1506
US

IV. Provider business mailing address

31 E MAIN ST
CANTON PA
17724-1506
US

V. Phone/Fax

Practice location:
  • Phone: 570-673-8833
  • Fax: 570-673-7066
Mailing address:
  • Phone: 570-673-8833
  • Fax: 570-673-7066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number053744-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS036443
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: