Healthcare Provider Details

I. General information

NPI: 1174704696
Provider Name (Legal Business Name): TITUSVILLE HOSPITAL DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 W OAK ST
TITUSVILLE PA
16354-1404
US

IV. Provider business mailing address

406 W OAK ST
TITUSVILLE PA
16354-1499
US

V. Phone/Fax

Practice location:
  • Phone: 800-950-1851
  • Fax: 814-827-8419
Mailing address:
  • Phone: 800-950-1851
  • Fax: 814-827-8419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RICHARD A SMITH
Title or Position: DIRECTOR CLINIC OPERATIONS
Credential:
Phone: 800-950-1851