Healthcare Provider Details

I. General information

NPI: 1487172359
Provider Name (Legal Business Name): KIDDOS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6583 STATE ROUTE 819 S STE 1
MT PLEASANT PA
15666-3503
US

IV. Provider business mailing address

6583 STATE ROUTE 819 S STE 1
MT PLEASANT PA
15666-3503
US

V. Phone/Fax

Practice location:
  • Phone: 724-542-4818
  • Fax: 724-542-4828
Mailing address:
  • Phone: 724-542-4818
  • Fax: 724-542-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberDS035406
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS030164L
License Number StatePA

VIII. Authorized Official

Name: MARILOU DIBAGNO
Title or Position: OFFICE MANAGER
Credential:
Phone: 724-542-4818