Healthcare Provider Details

I. General information

NPI: 1285644559
Provider Name (Legal Business Name): G. PETER MOYLAN, III D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 W MAIN ST
NORTH EAST PA
16428-1135
US

IV. Provider business mailing address

35 W MAIN ST
NORTH EAST PA
16428-1135
US

V. Phone/Fax

Practice location:
  • Phone: 814-725-1223
  • Fax:
Mailing address:
  • Phone: 814-725-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS024915L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: