Healthcare Provider Details

I. General information

NPI: 1710945654
Provider Name (Legal Business Name): RALPH HAIME CIVJAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 3RD ST 2ND FLOOR
EASTON PA
18042-1869
US

IV. Provider business mailing address

80 SUTTON PL
EASTON PA
18045-5757
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-7330
  • Fax: 610-250-2735
Mailing address:
  • Phone: 610-252-7681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5256838
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS037465
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: