=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720157084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOSHANNON VALLEY FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 439 SPRING ST
-----------------------------------------------------
City | HOUTZDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16651-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-378-7479
-----------------------------------------------------
Fax | 814-378-7439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 439 SPRING ST
-----------------------------------------------------
City | HOUTZDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16651-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-378-7479
-----------------------------------------------------
Fax | 814-378-7439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RECEPTIONIST
-----------------------------------------------------
Name | MISS AMY L BRITTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-378-7479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS031452L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS029496L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------