Provider Demographics
NPI:1992526586
Name:EPP PENNSYLVANIA PLLC
Entity type:Organization
Organization Name:EPP PENNSYLVANIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTOLLINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-450-0763
Mailing Address - Street 1:PO BOX 1584
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-1584
Mailing Address - Country:US
Mailing Address - Phone:315-450-0763
Mailing Address - Fax:
Practice Address - Street 1:1220 VALLEY FORGE RD STE 40
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-2676
Practice Address - Country:US
Practice Address - Phone:610-917-9984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty