Provider Demographics
NPI:1487172359
Name:KIDDOS PC
Entity type:Organization
Organization Name:KIDDOS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILOU
Authorized Official - Middle Name:
Authorized Official - Last Name:DIBAGNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-542-4818
Mailing Address - Street 1:6583 STATE ROUTE 819 S STE 1
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:PA
Mailing Address - Zip Code:15666-3503
Mailing Address - Country:US
Mailing Address - Phone:724-542-4818
Mailing Address - Fax:724-542-4828
Practice Address - Street 1:6583 STATE ROUTE 819 S STE 1
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:PA
Practice Address - Zip Code:15666-3503
Practice Address - Country:US
Practice Address - Phone:724-542-4818
Practice Address - Fax:724-542-4828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0354061223D0004X
PADS030164L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Multi-Specialty