Provider Demographics
NPI:1720422009
Name:EDWARD J. KOLONSKY DMD PC
Entity type:Organization
Organization Name:EDWARD J. KOLONSKY DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOLONSKY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-462-4710
Mailing Address - Street 1:437 W LLOYD ST
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:PA
Mailing Address - Zip Code:17976-1555
Mailing Address - Country:US
Mailing Address - Phone:570-462-4710
Mailing Address - Fax:
Practice Address - Street 1:27 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:PA
Practice Address - Zip Code:17976-1708
Practice Address - Country:US
Practice Address - Phone:570-462-4710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026931L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011724020001Medicaid