Provider Demographics
NPI:1306991005
Name:PLEASANT VALLEY DENTAL
Entity type:Organization
Organization Name:PLEASANT VALLEY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESDIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MARCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:814-944-0607
Mailing Address - Street 1:305 CAYUGA AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-4323
Mailing Address - Country:US
Mailing Address - Phone:814-944-0607
Mailing Address - Fax:814-944-0587
Practice Address - Street 1:305 CAYUGA AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4323
Practice Address - Country:US
Practice Address - Phone:814-944-0607
Practice Address - Fax:814-944-0587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADX0016241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID NUMBER