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General NPI Number Information
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NPI Number | 1245301381
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Entity Type | Organization
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Legal Business Name | BACK MOUNTAIN DENTAL, INC.
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Dates
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Enumeration Date | 11/12/2006
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Last Update Date | 11/04/2009
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Provider Practice Location Address
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Address Line | 210 CARVERTON RD
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City | TRUCKSVILLE
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State | PA
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Zip | 18708-1745
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Country | US
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Telephone | 570-696-1105
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Fax | 570-696-4805
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Provider Business Mailing Address
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Address Line | 210 CARVERTON RD
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City | TRUCKSVILLE
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State | PA
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Zip | 18708-1745
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Country | US
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Telephone | 570-696-1105
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Fax | 570-696-4805
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAMES CLEMENS DEFINNIS
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Credential | D.M.D
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Telephone | 570-696-1105
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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 | DS031113L
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License Number State | PA
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