Healthcare Provider Details

I. General information

NPI: 1275905929
Provider Name (Legal Business Name): KEYSTONE OMFS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 FOUR MILE DR
WILLIAMSPORT PA
17701-1940
US

IV. Provider business mailing address

1701 FOUR MILE DR
WILLIAMSPORT PA
17701-1940
US

V. Phone/Fax

Practice location:
  • Phone: 570-323-1900
  • Fax: 570-323-6079
Mailing address:
  • Phone: 570-323-1900
  • Fax: 570-323-6079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS029213L
License Number StatePA

VIII. Authorized Official

Name: DR. MARC S ROSENTHAL
Title or Position: OWNER
Credential: DMD MD
Phone: 570-323-1900