Provider Demographics
NPI:1699234641
Name:SUSQUEHANNA VALLEY DENTAL GROUP PC
Entity type:Organization
Organization Name:SUSQUEHANNA VALLEY DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMEONE-GILROY
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:570-655-7645
Mailing Address - Street 1:457 N MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-2185
Mailing Address - Country:US
Mailing Address - Phone:570-655-7645
Mailing Address - Fax:570-299-7427
Practice Address - Street 1:312 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:PA
Practice Address - Zip Code:17842-1106
Practice Address - Country:US
Practice Address - Phone:570-837-5117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty