Healthcare Provider Details

I. General information

NPI: 1417059148
Provider Name (Legal Business Name): CHARLES JOSEPH MUSTO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 WYOMING AVE STE 104
FORTY FORT PA
18704-3970
US

IV. Provider business mailing address

920 WYOMING AVE STE 203
FORTY FORT PA
18704-3999
US

V. Phone/Fax

Practice location:
  • Phone: 570-283-3611
  • Fax: 570-283-3396
Mailing address:
  • Phone: 570-283-3611
  • Fax: 570-283-3396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDP027522A
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS027522L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: