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General NPI Number Information
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NPI Number | 1043626450
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Entity Type | Organization
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Legal Business Name | COSMETIC DENTISTRY INC
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Dates
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Enumeration Date | 07/07/2014
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Last Update Date | 07/07/2014
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Provider Practice Location Address
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Address Line | 110 RADNOR RD SUITE 200
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City | STATE COLLEGE
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State | PA
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Zip | 16801-7987
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Country | US
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Telephone | 814-238-2020
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Fax |
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Provider Business Mailing Address
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Address Line | 110 RADNOR RD SUITE 200
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City | STATE COLLEGE
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State | PA
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Zip | 16801-7987
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Country | US
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Telephone | 814-238-2020
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Fax |
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Authorized Official
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Title or Position | OWNER, PRESIDENT
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Name | MR. ROBERT LEON JEANMENNE
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Credential | DDS
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Telephone | 814-238-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DS035349
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License Number State | PA
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