Healthcare Provider Details

I. General information

NPI: 1003044264
Provider Name (Legal Business Name): VINCENT I. DISALVO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 06/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E 4TH ST
WILLIAMSPORT PA
17701-6303
US

IV. Provider business mailing address

121 E 4TH ST
WILLIAMSPORT PA
17701-6303
US

V. Phone/Fax

Practice location:
  • Phone: 570-322-4741
  • Fax: 570-323-6110
Mailing address:
  • Phone: 570-322-4741
  • Fax: 570-323-6110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS015354L
License Number StatePA

VIII. Authorized Official

Name: DR. VINCENT I DISALVO
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 570-322-4741