Healthcare Provider Details

I. General information

NPI: 1891711388
Provider Name (Legal Business Name): MIMOSA FAMILY DENTISTRY, PC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W CHERRY ST
PALMYRA PA
17078-2303
US

IV. Provider business mailing address

117 W CHERRY ST
PALMYRA PA
17078-2303
US

V. Phone/Fax

Practice location:
  • Phone: 717-838-1338
  • Fax: 717-838-7003
Mailing address:
  • Phone: 717-838-1338
  • Fax: 717-838-7003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS-027312-L
License Number StatePA

VIII. Authorized Official

Name: MR. LOC NGUYEN BUI
Title or Position: OWNER/ DENTIST
Credential: D.M.D.
Phone: 717-838-1338