Healthcare Provider Details

I. General information

NPI: 1053617415
Provider Name (Legal Business Name): ANTHONY JOHN CIPOLLA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W 4TH ST
WILLIAMSPORT PA
17701-6038
US

IV. Provider business mailing address

520 W 4TH ST
WILLIAMSPORT PA
17701-6038
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-9551
  • Fax:
Mailing address:
  • Phone: 570-326-9551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS023912L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: