Healthcare Provider Details

I. General information

NPI: 1124580188
Provider Name (Legal Business Name): EDP OF PENNSYLVANIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7546 STATE ROUTE 30
IRWIN PA
15642-7528
US

IV. Provider business mailing address

7546 STATE ROUTE 30
IRWIN PA
15642-7528
US

V. Phone/Fax

Practice location:
  • Phone: 800-312-1279
  • Fax:
Mailing address:
  • Phone: 312-800-1270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TANYA MILLER
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 913-951-9644