Provider Demographics
NPI:1992879001
Name:WESTERN PENNSYLVANIA DENTAL GROUP
Entity type:Organization
Organization Name:WESTERN PENNSYLVANIA DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:241 SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3219
Mailing Address - Country:US
Mailing Address - Phone:814-266-9535
Mailing Address - Fax:814-266-9305
Practice Address - Street 1:241 SCHOOLHOUSE RD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3219
Practice Address - Country:US
Practice Address - Phone:814-266-9535
Practice Address - Fax:814-266-9305
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN PENNSYLVANIA DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-20
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029923L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty