Healthcare Provider Details

I. General information

NPI: 1245537604
Provider Name (Legal Business Name): CANDICE NICOLE GHAZZOULI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CANDICE NICOLE CARPENTER DMD

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 SYCAMORE RD SUITE A
MONTOURSVILLE PA
17754-9314
US

IV. Provider business mailing address

1660 SYCAMORE RD SUITE A
MONTOURSVILLE PA
17754-9314
US

V. Phone/Fax

Practice location:
  • Phone: 570-323-4819
  • Fax: 570-323-7057
Mailing address:
  • Phone: 570-323-4819
  • Fax: 570-323-7057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS037471
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: