Healthcare Provider Details

I. General information

NPI: 1811668957
Provider Name (Legal Business Name): DENTAL ARTS OF ERIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 PEACH ST
ERIE PA
16509-1443
US

IV. Provider business mailing address

4330 PEACH ST
ERIE PA
16509-1443
US

V. Phone/Fax

Practice location:
  • Phone: 814-315-6209
  • Fax:
Mailing address:
  • Phone: 814-315-6209
  • Fax:

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: DR. TIMOTHY THEISEN
Title or Position: OWNER
Credential: DMD
Phone: 814-315-6209