Healthcare Provider Details

I. General information

NPI: 1487958500
Provider Name (Legal Business Name): JAMES C.A. MACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HIGHLAND AVENUE
NEW STANTON PA
15672
US

IV. Provider business mailing address

110 HIGHLAND AVENUE P.O. BOX 65
NEW STANTON PA
15672
US

V. Phone/Fax

Practice location:
  • Phone: 724-925-6010
  • Fax: 724-925-8631
Mailing address:
  • Phone: 724-925-6010
  • Fax: 724-925-8631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS020328L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: