=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710482203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLEVUE DENTAL PARTNERS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2018
-----------------------------------------------------
Last Update Date | 12/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 539 LINCOLN AVE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15202-3548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-734-3664
-----------------------------------------------------
Fax | 412-734-3998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 539 LINCOLN AVE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15202-3548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-734-3664
-----------------------------------------------------
Fax | 412-734-3998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE BILLER
-----------------------------------------------------
Name | SUSAN SNOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-734-3664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS020662L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------