=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255499539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN FISHBAINE, DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 476 ROLLING RIDGE DR SUITE 110
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16801-7639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-238-6800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 476 ROLLING RIDGE DR SUITE 110
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16801-7639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-238-6800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEVEN FISHBAINE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 814-238-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS023721L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------