Healthcare Provider Details

I. General information

NPI: 1093048217
Provider Name (Legal Business Name): ELECTRIC CITY DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 09/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 MAIN ST
FOREST CITY PA
18421-1440
US

IV. Provider business mailing address

305 SCHOOL SIDE DR
THROOP PA
18512-1456
US

V. Phone/Fax

Practice location:
  • Phone: 570-785-3000
  • Fax: 570-785-3175
Mailing address:
  • Phone: 570-383-0784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS035200
License Number StatePA

VIII. Authorized Official

Name: RICHARD A HARTLAND II
Title or Position: PRESIDENT
Credential: DMD
Phone: 570-383-0784