MEDICARE: BACK MOUNTAIN PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1013789452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK MOUNTAIN PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	126 SENECA DR
Second Line	:
City	:	OLD FORGE
State	:	PA
Zip	:	18518-1598
Country	:	US
Telephone Number	:	570-885-9531
Fax Number	:

Provider Business Practice Location Address
First Line	:	3784 YALICK PLZ UNIT 1
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-7719
Country	:	US
Telephone Number	:	570-456-5566
Fax Number	:

Authorized Official
Title or Position	:	OWNER PEDIATRIC DENTIST
Name	:	DR. JESSICA MARIE PIZANO
Credential	:	DMD, MS
Telephone Number	:	570-885-9531

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	10/30/2023

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Directions to “BACK MOUNTAIN PEDIATRIC DENTISTRY ” Practice Location

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