MEDICARE: KIDDOS PC

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	1223D0004X	Dental Anesthesiology	DS035406	PA
2	1223P0221X	Pediatric Dentistry	DS030164L	PA

General Provider Information

NPI Number	:	1487172359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDDOS PC

Provider Business Mailing Address
First Line	:	6583 STATE ROUTE 819 S STE 1
Second Line	:
City	:	MT PLEASANT
State	:	PA
Zip	:	15666-3503
Country	:	US
Telephone Number	:	724-542-4818
Fax Number	:	724-542-4828

Provider Business Practice Location Address
First Line	:	6583 STATE ROUTE 819 S STE 1
Second Line	:
City	:	MT PLEASANT
State	:	PA
Zip	:	15666-3503
Country	:	US
Telephone Number	:	724-542-4818
Fax Number	:	724-542-4828

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MARILOU DIBAGNO
Credential	:
Telephone Number	:	724-542-4818

Provider Enumeration Date	:	08/31/2017
Last Update Date	:	07/21/2022

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Directions to “KIDDOS PC ” Practice Location

Language	Start Address	Practice Location

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