Healthcare Provider Details

I. General information

NPI: 1255664819
Provider Name (Legal Business Name): TIOGA DENTAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 E LAWRENCE RD
LAWRENCEVILLE PA
16929-8801
US

IV. Provider business mailing address

34 E LAWRENCE RD
LAWRENCEVILLE PA
16929-8801
US

V. Phone/Fax

Practice location:
  • Phone: 570-724-9145
  • Fax: 570-724-5397
Mailing address:
  • Phone: 570-724-9145
  • Fax: 570-724-5397

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: DR. ALICIA ANNE RISNER-BAUMAN
Title or Position: DENTAL CLINIC DIRECTOR
Credential: DDS, FADPD
Phone: 570-827-0145