Healthcare Provider Details

I. General information

NPI: 1639614837
Provider Name (Legal Business Name): NORTHEAST DENTAL SURGERY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1073 OAK ST B STE
PITTSTON PA
18640-3716
US

IV. Provider business mailing address

1073 OAK ST B STE
PITTSTON PA
18640-3716
US

V. Phone/Fax

Practice location:
  • Phone: 570-237-1838
  • Fax:
Mailing address:
  • Phone: 570-237-1838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MR. SHAWN M CASEY
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 570-237-1838