=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174275945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 42 NORTH DENTAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2022
-----------------------------------------------------
Last Update Date | 01/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1660 SYCAMORE RD
-----------------------------------------------------
City | MONTOURSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17754-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-323-4819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 5TH AVE FL 3
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-8759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF CLINICAL OFFICER
-----------------------------------------------------
Name | MICHAEL ANGELO SCIALABBA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-512-2709
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------