MEDICARE: ANTRIM DENTAL CARE LLC

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	1223G0001X	General Practice Dentistry	DS030141L	PA

General Provider Information

NPI Number	:	1811106230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTRIM DENTAL CARE LLC

Provider Business Mailing Address
First Line	:	196 S WASHINGTON ST
Second Line	:
City	:	GREENCASTLE
State	:	PA
Zip	:	17225-1332
Country	:	US
Telephone Number	:	717-597-7424
Fax Number	:

Provider Business Practice Location Address
First Line	:	196 S WASHINGTON ST
Second Line	:
City	:	GREENCASTLE
State	:	PA
Zip	:	17225-1332
Country	:	US
Telephone Number	:	717-597-7424
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. JUSTIN CODY HOLLINGSHEAD
Credential	:	D.M.D.
Telephone Number	:	717-597-7424

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	03/04/2015

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