=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538255856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS G. LOPATOFSKY, DMD, NICOLE M. QUEZADA, DMD,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11671 ROUTE 6
-----------------------------------------------------
City | WELLSBORO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16901-6750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-724-2565
-----------------------------------------------------
Fax | 570-724-3240
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11671 ROUTE 6
-----------------------------------------------------
City | WELLSBORO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16901-6750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-724-2565
-----------------------------------------------------
Fax | 570-724-3240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JENNIFER LYNN CLEMENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-724-2565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS027186L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS027194L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------