Provider Demographics
NPI:1104491653
Name:CDA LAKE WINOLA LLC
Entity type:Organization
Organization Name:CDA LAKE WINOLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:J
Authorized Official - Last Name:HANYON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-378-3305
Mailing Address - Street 1:1220 PA-307
Mailing Address - Street 2:
Mailing Address - City:FACTORYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18419
Mailing Address - Country:US
Mailing Address - Phone:570-378-3305
Mailing Address - Fax:570-378-3430
Practice Address - Street 1:1220 PA-307
Practice Address - Street 2:
Practice Address - City:FACTORYVILLE
Practice Address - State:PA
Practice Address - Zip Code:18419
Practice Address - Country:US
Practice Address - Phone:570-378-3305
Practice Address - Fax:570-378-3430
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CDA LAKE WINOLA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty