Provider Demographics
NPI:1194115121
Name:5TH AVENUE DENTAL
Entity type:Organization
Organization Name:5TH AVENUE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:V
Authorized Official - Last Name:ARNOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-272-9552
Mailing Address - Street 1:1230 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7814
Mailing Address - Country:US
Mailing Address - Phone:717-272-9552
Mailing Address - Fax:717-272-9545
Practice Address - Street 1:1230 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7814
Practice Address - Country:US
Practice Address - Phone:717-272-9552
Practice Address - Fax:717-272-9545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019581L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty