Healthcare Provider Details

I. General information

NPI: 1326186743
Provider Name (Legal Business Name): PROGRESSIVE DENTAL CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 FAME AVE SUITE 206
HANOVER PA
17331-1587
US

IV. Provider business mailing address

PO BOX 471
HANOVER PA
17331-0471
US

V. Phone/Fax

Practice location:
  • Phone: 717-637-0202
  • Fax: 717-637-5855
Mailing address:
  • Phone: 717-637-0202
  • Fax: 717-637-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number24985
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number36615
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number28116
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22314
License Number StatePA

VIII. Authorized Official

Name: DR. TERRY M GORDON
Title or Position: VICE PRESIDENT
Credential: DDS
Phone: 717-637-0202