MEDICARE: COOPERSBURG DENTAL PLLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1508453036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOPERSBURG DENTAL PLLC

Provider Business Mailing Address
First Line	:	457 N MAIN ST STE 100
Second Line	:
City	:	PITTSTON
State	:	PA
Zip	:	18640-2185
Country	:	US
Telephone Number	:	570-655-7645
Fax Number	:	570-299-7427

Provider Business Practice Location Address
First Line	:	20 S MAIN ST
Second Line	:
City	:	COOPERSBURG
State	:	PA
Zip	:	18036-1911
Country	:	US
Telephone Number	:	610-282-1700
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	ELIZABETH GALVIN
Credential	:
Telephone Number	:	570-655-7645

Provider Enumeration Date	:	12/30/2020
Last Update Date	:	12/30/2020

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Directions to “COOPERSBURG DENTAL PLLC ” Practice Location

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