=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336785013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD ORTHODONTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2019
-----------------------------------------------------
Last Update Date | 11/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 WASHINGTON STREET
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-225-1114
-----------------------------------------------------
Fax | 724-223-0238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 WASHINGTON STREET
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-225-1114
-----------------------------------------------------
Fax | 724-223-0238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MS. REGINA GOOD ROMANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-445-4660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------