Provider Demographics
NPI:1104902873
Name:SMATLAK & GISLIOTTI, DMD, PC
Entity type:Organization
Organization Name:SMATLAK & GISLIOTTI, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:PEACE
Authorized Official - Last Name:GIGLIOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:814-938-8554
Mailing Address - Street 1:203 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767
Mailing Address - Country:US
Mailing Address - Phone:814-938-8554
Mailing Address - Fax:814-938-8559
Practice Address - Street 1:203 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767
Practice Address - Country:US
Practice Address - Phone:814-938-8554
Practice Address - Fax:814-938-8559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022899L1223G0001X
PADS020705L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001945347001Medicaid
PA0019453470001Medicaid
PA0010829130001Medicaid