Basic Information
| Provider Information | |||||||||
| NPI: | 1164590998 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POCONO KIDS DENTAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEHIGH VALLEY HOSPITAL POCONO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 E BROWN ST | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704204938 | ||||||||
| FaxNumber: | 5704204948 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 E BROWN ST STE 114 | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704763506 | ||||||||
| FaxNumber: | 5704219014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARCHOZZI | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4848623943 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POCONO MEDICAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.