Provider Demographics
NPI:1174704696
Name:TITUSVILLE HOSPITAL DENTAL GROUP
Entity type:Organization
Organization Name:TITUSVILLE HOSPITAL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-950-1851
Mailing Address - Street 1:406 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-1499
Mailing Address - Country:US
Mailing Address - Phone:800-950-1851
Mailing Address - Fax:814-827-8419
Practice Address - Street 1:406 W OAK ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1404
Practice Address - Country:US
Practice Address - Phone:800-950-1851
Practice Address - Fax:814-827-8419
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TITUSVILLE AREA HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007460650026Medicaid