Healthcare Provider Details

I. General information

NPI: 1023788494
Provider Name (Legal Business Name): FACIAL 32 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 EICHELBERGER ST
HANOVER PA
17331-1365
US

IV. Provider business mailing address

1750 YOUNGS RD
HANOVER PA
17331-9451
US

V. Phone/Fax

Practice location:
  • Phone: 443-257-7014
  • Fax:
Mailing address:
  • Phone: 443-257-7014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DIANA EUGENIA SHOE
Title or Position: AUTHORIZED MEMBER
Credential: DDS
Phone: 443-257-7014