Healthcare Provider Details

I. General information

NPI: 1619225810
Provider Name (Legal Business Name): PENNSYLVANIA CENTER FOR DENTAL SLEEP MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2012
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 CARLISLE ST STE 1B
HANOVER PA
17331
US

IV. Provider business mailing address

1225 CARLISLE ST STE 1B
HANOVER PA
17331-1207
US

V. Phone/Fax

Practice location:
  • Phone: 717-632-1332
  • Fax: 270-637-0207
Mailing address:
  • Phone: 717-632-1332
  • Fax: 270-637-0207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number24985
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. TERRY M GORDON
Title or Position: PRESIDENT/DENTAL DIRECTOR
Credential: DDS
Phone: 717-632-1332