Healthcare Provider Details

I. General information

NPI: 1841055274
Provider Name (Legal Business Name): PENN FAMILY DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 W PARK AVE STE 11
DU BOIS PA
15801-2277
US

IV. Provider business mailing address

190 W PARK AVE STE 11
DU BOIS PA
15801-2277
US

V. Phone/Fax

Practice location:
  • Phone: 814-913-8136
  • Fax: 814-509-4312
Mailing address:
  • Phone: 814-913-8136
  • Fax: 814-509-4312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: EDWARD BIENVENIDO MINAYA
Title or Position: PRESIDENT
Credential:
Phone: 814-232-7985