Healthcare Provider Details

I. General information

NPI: 1538468475
Provider Name (Legal Business Name): STATE COLLEGE ORTHODONTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 PARK CENTER BLVD SUITE 300
STATE COLLEGE PA
16801-3007
US

IV. Provider business mailing address

2565 PARK CENTER BLVD SUITE 300
STATE COLLEGE PA
16801-3007
US

V. Phone/Fax

Practice location:
  • Phone: 814-308-9504
  • Fax: 814-954-7723
Mailing address:
  • Phone: 814-308-9504
  • Fax: 814-954-7723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS035437
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. DIANE MARIE RAY
Title or Position: PRESIDENT
Credential: D.M.D., M.S.
Phone: 814-308-9504