=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134560394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILL CREEK DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2013
-----------------------------------------------------
Last Update Date | 07/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 497 N CLAUDE A LORD BLVD
-----------------------------------------------------
City | POTTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17901-2705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-516-9109
-----------------------------------------------------
Fax | 570-516-9138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 497 N CLAUDE A LORD BLVD
-----------------------------------------------------
City | POTTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17901-2705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-516-9109
-----------------------------------------------------
Fax | 570-516-9138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DAVID PELAGIO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 570-516-9109
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS031640L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------