=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316044431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOOSIC DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 06/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 CHURCH STREET
-----------------------------------------------------
City | MOOSIC
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-344-3500
-----------------------------------------------------
Fax | 570-344-9442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 CHURCH STREET
-----------------------------------------------------
City | MOOSIC
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-344-3500
-----------------------------------------------------
Fax | 570-344-9442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NOLEN SCOTT ELY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-344-3500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS030419L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------