Healthcare Provider Details

I. General information

NPI: 1427392943
Provider Name (Legal Business Name): WESTERN PENNSYLVANIA DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 WARREN ST STE 150
JOHNSTOWN PA
15905-3443
US

IV. Provider business mailing address

322 WARREN ST STE 150
JOHNSTOWN PA
15905-3443
US

V. Phone/Fax

Practice location:
  • Phone: 814-619-2410
  • Fax:
Mailing address:
  • Phone: 814-619-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS029676L
License Number StatePA

VIII. Authorized Official

Name: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100