Healthcare Provider Details

I. General information

NPI: 1528364932
Provider Name (Legal Business Name): DENTAL SPECIALISTS OF NORTHEAST PA ROOT CANAL & IMPLANT DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W 15TH ST
HAZLETON PA
18201-2707
US

IV. Provider business mailing address

905 W 15TH ST
HAZLETON PA
18201-2707
US

V. Phone/Fax

Practice location:
  • Phone: 570-459-2100
  • Fax: 570-459-1617
Mailing address:
  • Phone: 570-459-2100
  • Fax: 570-459-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS035059
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS017029L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. PAUL R. MANCIA
Title or Position: OWNER
Credential: D.S.S.
Phone: 570-459-2100